MEDRC Series of R & D Reports

MEDRC Project: 14-CoE-001

Parasitic Infection Among Farmers Dealing With Treated Wastewater In

Al-Zaitoun Area, Gaza City

MSc. Thesis By

Haneen Nabil Al-Sbaihi

B.Sc.: Environmental Engineering- Islamic University of Gaza-Palestine

Supervisor: Dr. Khalid Qahman

Assistant Professor – Environment Quality Authority

Co-Supervisor: Prof. Adnan Al-Hindi

Professor – Faculty of Health Sciences -Islamic University of Gaza

A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree

of Master in Public Health - Epidemiology

The Middle East Desalination Research Center

Muscat

Sultanate of Oman

Date: 29/05/2017

Deanship of Graduate Studies

Al-Quds University

Parasitic Infection Among Farmers Dealing With

Treated Wastewater In Al-Zaitoun Area, Gaza City

Haneen Nabil Al-Sbaihi

MPH Thesis

Jerusalem- Palestine

1438 / 2017

Parasitic Infection Among Farmers Dealing With

Treated Wastewater In Al-Zaitoun Area, Gaza City

Prepared By:

Haneen Nabil Al-Sbaihi

B.Sc.: Environmental Engineering- Islamic University of

Gaza-Palestine

Supervisor: Dr. Khalid Qahman

Assistant Professor – Environment Quality Authority

Co-Supervisor: Prof. Adnan Al-Hindi

Professor – Faculty of Health Sciences -Islamic University

of Gaza

A thesis Submitted in Partial fulfillment of requirements for

the degree of Master of Public Health/Epidemiology-

Al- Quds University

1438 / 2017

noidacideD

I would like to dedicate my thesis and everything I do

To my father and my mother for their endless love, support and continuous

encouragement. Without their love and support I will not be who I am today.

To my brothers and sisters Nour, Ramy, Fatima, Hanan, Reem, Wafaa ,

Mohammed, Ahmed, and Belal.

To the soul of my first teacher Eng. Jamal Al-Dadah, who guide me for

treated wastewater reuse science.

To my close friends Alaa' and Rasha.

To every person who give others without waiting their acknowledgement.

To all those who encouraged and helped me to complete this work.

To all of them I dedicate this work.

Haneen Nabil Al-Sbaihi

I

II

Acknowledgement

First and foremost, I thank Allah, the generous, for made this humble effort to become a

reality, and giving me strength and courage until this study is finally completed.

Deep special thanks and heartiest appreciation for my parents for their support and

patience.

Thanks and deepest regards for my supervisors for their support and supervision.

Thanks for my sister Fatima and my brother Mohammed for their support. Special thanks

to my brother Eng. Belal who accompanied me in all field works, I am extremely grateful

his assistance in data and samples collection.

My success and my achievement in Master study is attributed to the extensive support and

financial assistance from Islamic Development Bank, I would like to express my grateful

gratitude and sincere appreciation to them for assisting me to obtain on this scientific

degree.

Thanks for Middle East Desalination Research Center for their contribution in providing

me with some funds for lab analysis. My deep special thanks and heartiest appreciation for

Eng. Ahmed Baraka and all PWA staff for their support.

Thanks to all the faculty members of School of Public Health, Al-Quds University for

supporting their students.

I would like to thank all experts, who helped me in reviewing the questionnaire and special

thanks for Dr. Khalid El-Mghari for his kind advices in data analysis.

I am indebted for Eng. Abdallah Gazal, Chemical Engineer at GWWTP for his kind

support and help, really his help contributed in directing this research to the light.

My grateful gratitude and sincere appreciation for Dr. Magdy Dhair, Dr. Nedal

Ghuneim, and Dr. Mohammed Salem for their support in treatment the infected farmers.

Special thanks to all farmers who participated in this study especially Mr. Ramadan

Eshtawi , Mr. Jamil Abu Zour, Mr. Wael Ashour, and Mr. Salem Ashour for their

help and support in field work coordination.

Thanks and deepest regard for all my colleagues at UNRWA Eng. Alaa' El-karriri, Mr.

Adel Eid, Eng. Mohammed El-Farran, Mr. Shafiq Abu Jaser, and Eng. Mousa

Kreizem for their support and encouragement.

Finally, I would like to express my sincere thanks to all my friends who support and

encourage me Alaa' Dokhan, Awatif Abd El Qader, Heba Arafat, Mariam Al-Refi ,

Maysoon Abu Rabee, Mai El-Derawi, Rasha Al-Aswad, and Rania Ghuneim.

With respect

Haneen Nabil Al-Sbaihi

III

Abstract

Treated wastewater irrigation is associated with several benefits but can also lead to significant

health risks. The main objective of this study is to investigate the parasitic infection (PI) among

farmers dealing with treated wastewater (TWW) in Al-Zaitoun area, Gaza City. This study included

two farmer groups: farmers who dealing with TWW (Mixed water users (MWUs)), and farmers

who irrigate by using groundwater (GW) (Ground water users (GWUs)). Each participant was

asked to provide stool samples. Soil, irrigation water, and hand washing water samples were taken

from each participant in addition to interview structured questionnaire was filled with all of them.

Prevalence of PI was 30.9% and increased to be 47.3% in the 2nd

phase which was after using

TWW for 3 months. Positive association statically significant was found between PI and TWWR in

the 2nd

phase (OR=1.37, CI 0.448-4.21). Six parasites species were identified among participants:

Entamoeba ''histolytica/dispar and coil'', Cryptosporidium, Microsporidia, Giardia lamblia,

Strongyloides stercoralis, and Ascaris lumbricoides. Prevalence of soil parasitic contamination

was 54.5% and increased statically significant to be 61.5% in the 2nd

phase. Negative association

not statically significant was found between irrigation water type and parasitic soil contamination

(OR 1st

=0.813, CI 0.265-2.495) and (OR2nd

=0.897, CI 0.28-2.876). The highest PI was found

between females, participants age ≤ 18 year, participants who had the least Academic

qualification, who work in agriculture for period of ≤10 years, and who work ≤ 6 hours per day in

the farm. Participants who had less family size and who previously had ant-parasitic drugs had

less PI with SSR. High PI was found between participants who had bad financially status, who had

landless areas inside their homes, who work in farm far away from their homes, who is a new user

for TWW and irrigate more agricultural dunums by it, who didn’t work mainly in agriculture, who

use fertilizers with TWW, who hadn't toilet in their farm, who disposed from their home and farm

toilet into the farm and cesspits respectively, who breed animals/birds in places non- closed inside

or beside their farms, who previously diagnosed for intestinal parasites, and who had less HB

mean. Non-drinking water consumption per person per day was least at parasitic infected

participants. Generally MWUs HB was better than GWUs HB inside home and through harvesting

process, but it was less through working in the farm. It was found the HB for MWUs through using

TWW periods had increased to be the best.

In spite of, increasing MWUs HB with using TWW, MWUs were working in soils less parasitic

contaminated, and they also use localized irrigation technique, it was found a positive not

statically significant relationship between PI and using TWW in irrigation, may this attributed for

increasing the infection opportunity between MWUs as a result of increasing soil microorganisms

activity in their soils by increasing soil organic matter from using TWW, in addition to 80% of

participants who within age group ≤ 18 year '' who hosting more parasites'' were from MWUs.

Key words: Wastewater, Groundwater, Treated wastewater, Hygiene behavior, Parasitic infection

IV

Table of content

Declaration .......................................................................................................................................... I

Acknowledgement .............................................................................................................................. II

Abstract ............................................................................................................................................ III

Table of content ................................................................................................................................ IV

List of tables ..................................................................................................................................... XI

List of figures ................................................................................................................................... XI

List of annexes .............................................................................................................................. XIV

List of abbreviations ........................................................................................................................ XV

Centers for Disease Control and Prevention ................................................................................... XV

Chapter I ............................................................................................................................................. 1

Introduction ........................................................................................................................................ 1

1.1 Background .................................................................................................................................. 1

1.2 Problem Statement ....................................................................................................................... 2

1.3 Problem Justification .................................................................................................................... 3

1.4 Objectives .................................................................................................................................... 4

1.4.1. Main objective……………… ............................................................................................. 4

1.4.2. Specific objectives……........................................................................................................ 4

1.5 Context of Study………............................................................................................................... 4

1.5.1. Demographic and Socio- economic Context ........................................................................ 4

1.5.2. Environmental and health factors ......................................................................................... 5

1.6 Operational Definitions………………………………………………… .................................... 5

Chapter II ........................................................................................................................................... 7

Literature Review ............................................................................................................................... 7

2.1 Conceptual Framework ................................................................................................................ 7

2.2 Water Status in Gaza Strip ........................................................................................................... 9

2.3 Wastewater Status in Gaza Strip ................................................................................................ 10

2.3.1. Wastewater networks in the Gaza strip .............................................................................. 10

2.3.2. Wastewater treatment plants in Gaza strip ......................................................................... 10

2.3.3.1. Gaza wastewater treatment plant (GWTP) ...................................................................... 11

2.4 Agriculture ................................................................................................................................. 11

V

2.4.1. Irrigation water quantity in Gaza strip ............................................................................... 11

2.4.2. Irrigation water quality in Gaza strip ................................................................................. 12

2.4.3. Future water resources development for agriculture in the Gaza strip ............................... 12

2.5 Interest in Wastewater Reuse in the World ................................................................................ 12

2.6 Previous Experiences of Treated Wastewater Reuse in Gaza Strip ........................................... 13

2.6.1. Bedouin village pilot project: ............................................................................................. 13

2.6.2. Zaitoun area pilot project: .................................................................................................. 14

2.6.3. Al-Mawasi ( SAT)…………. ............................................................................................. 14

2.6.4 European hospital in Khanyounis project ........................................................................... 14

2.7 Effects of Wastewater Reuse in Agriculture .............................................................................. 14

2.7.1. Positive effects of treated wastewater use in agricultur ..................................................... 14

2.7.1.1. Environmental benefits ....................................................................................................... 14

2.7.1.2. Agricultural benefits ............................................................................................................ 15

2.7.1.3 Water resources management benefits: ................................................................................ 15

2.7.2 Negative effects of treated wastewater use in agriculture ................................................... 15

2.7.2.1 Environmental impacts ......................................................................................................... 15

2.7.2.2 Agricultural impacts ............................................................................................................. 16

2.8 Health Risks Associated with Treated Wastewater Irrigation .................................................... 16

2.8.1 Risks to agricultural workers and their families .................................................................. 17

2.9 Wastewater Microbial Contamination....................................................................................... 17

2.9.1 Wastewater pathogenic parasites......................................................................................... 18

2.9.1.1 Helminthes parasites ............................................................................................................ 18

2.9.1.2 Protozoan parasites ............................................................................................................... 18

2.9.2 Survival of parasites in environment ................................................................................... 19

2.10 Chain of Infection..................................................................................................................... 19

2.10.1. Type of infectious agent ................................................................................................... 19

2.10.2. Reservoir of the infectious agent ...................................................................................... 21

2.10.3. Mode of transmission….. ................................................................................................. 21

2.10.3.1. Person-to-Person transmission: ......................................................................................... 21

2.10.3.2. Waterborne transmission: .................................................................................................. 21

2.10.3.3. Foodborne transmission: ................................................................................................... 21

2.10.3.4. Airborne, Vector-Borne and Fomites transmission: .......................................................... 22

2.10.4. Portal of entry…………. .................................................................................................. 22

2.10.5. Host Susceptibility…… ................................................................................................... 22

2.11 Common Parasites Causing Waterborne Parasitic Diseases .................................................... 23

2.11.1. Strongyloides stercoralis .................................................................................................. 23

VI

2.11.1.1 S. stercoralis transmission ................................................................................................. 23

2.11.1.2. Strongyloidiasis symptoms ............................................................................................... 23

2.11.1.3. S. stercoralis disease .......................................................................................................... 23

2.11.1.4. S. stercoralis diagnosis ...................................................................................................... 23

2.11.1.5. Strongyloidiasis treatment ................................................................................................. 24

2.11.1.6. Prevention and control of S. stercoralis............................................................................. 24

2.11.1.7. S. stercoralis life cycle ...................................................................................................... 24

2.11.2 Ascaris lumbricoides….. ................................................................................................... 24

2.11.2.1. A. lumbricoides transmission ............................................................................................ 24

2.11.2.2. Ascariasis symptoms ......................................................................................................... 25

2.11.2.3. A. lumbricoides disease ..................................................................................................... 25

2.11.2.4. A. lumbricoides diagnosis ................................................................................................. 25

2.11.2.5. Ascariasis treatment .......................................................................................................... 25

2.11.2.6. Prevention and control of A. lumbricoides ....................................................................... 25

2.11.2.7. A. lumbricoides life cycle ................................................................................................. 26

2.11.3. Cryptosporidium sp…… .................................................................................................. 26

2.11.3.1 Cryptosporidium transmission .......................................................................................... 26

2.11.3.2. Cryptosporidiosis symptoms ............................................................................................. 26

2.11.3.3 Cryptosporidiosis ............................................................................................................... 27

2.11.3.4. Cryptosporidium diagnosis ............................................................................................... 27

2.11.3.5. Cryptosporidiosis treatment .............................................................................................. 27

2.11.3.6. Prevention and control of Cryptosporidiosis ..................................................................... 27

2.11.3.7. Cryptosporidium life cycle ................................................................................................ 27

2.11.4. Entamoeba histolytica… .................................................................................................. 28

2.11.4.1. E. histolytica transmission ................................................................................................. 28

2.11.3.2. E. histolytica disease ......................................................................................................... 28

2.11.4.3. Amebiasis symptoms........................................................................................................ 28

2.11.4.4. Amebiasis treatment .......................................................................................................... 28

2.11.4.5. E. histolytica diagnoses ..................................................................................................... 28

2.11.4.6. Prevention and control of E. histolytica ............................................................................ 29

2.11.4.7. E. histolytica Life cycle ..................................................................................................... 29

2.11.5. Giardia lamblia……….. ................................................................................................... 29

2.11.5.1. G. lamblia transmission ..................................................................................................... 29

2.11.5.2. G. lamblia symptoms......................................................................................................... 30

2.11.5.3. G. lamblia disease ............................................................................................................. 30

2.11.5.4. Giardiasis treatment ........................................................................................................... 30

VII

2.11.5.5.Prevention and control of G. lamblia disease ..................................................................... 30

2.11.5.6. G. lamblia life cycle .......................................................................................................... 30

2.11.6. Microsporidia………… ................................................................................................... 31

2.11.6.1. Microsporidia symptoms: .................................................................................................. 31

2.11.6.2. Microsporidia disease ........................................................................................................ 31

2.11.6.3. Microsporidia diagnosis .................................................................................................... 31

2.11.6.4. Microsporidia Treatment ................................................................................................... 31

2.11.6.5. Microsporidia life cycle .................................................................................................... 32

2.12 Health Protection Measure for Reduction Health Risks Associated with TWWR ................. 32

2.12.1. Reducing health risks associated with wastewater irrigation approaches ........................ 32

2.12.1.2.Wastewater treatment: ........................................................................................................ 32

2.12.1.3.Wastewater application and human exposure control: ....................................................... 32

2.12.1.4. Crop restriction .................................................................................................................. 33

2.12.1.5. Pathogen die-off before consumption: .............................................................................. 33

2.12.1.6. Chemotherapy and vaccination ......................................................................................... 34

2.13 Treated Wastewater Reuse Guidelines ..................................................................................... 34

Chapter III ........................................................................................................................................ 35

Methodology .................................................................................................................................... 35

3.1 Study Design .............................................................................................................................. 35

3.2 Study Population ........................................................................................................................ 35

3.3 Study Setting .............................................................................................................................. 35

3.3.1. Study areas…………….. ................................................................................................... 35

3.3.2 Study period……………. ................................................................................................... 36

3.4 Study Eligibility Criteria ............................................................................................................ 37

3.4.1. Inclusion criteria………. .................................................................................................... 37

3.4.2. Exclusion criteria………… ................................................................................................ 37

3.5 Study Instruments ....................................................................................................................... 37

3.5.1. Stool samples, Irrigation water, soil, and farmers hand washing water samples ............... 38

3.5.2. An interview structured questionnaire…… ........................................................................... 38

3.6 Ethical and Administrative Considerations ................................................................................ 40

3.7 Samples Size and Process .......................................................................................................... 40

3.7.1. Farmers participants…… ................................................................................................... 40

3.7.2. Stool samples…………...................................................................................................... 40

3.7.3. Treatment of the infected farmers in the first phase: .......................................................... 41

3.7.4. Soil samples……………. ................................................................................................... 41

3.7.5. Irrigation water samples… ................................................................................................. 41

VIII

3.7.6. Farmers Hand washing water samples ............................................................................... 42

3.8 Laboratory Procedure ................................................................................................................. 42

3.8.1 Equipment sterilization…. .................................................................................................. 42

3.8.2 Samples labeling………… ................................................................................................. 42

3.8.3 Samples preservation…… ................................................................................................... 42

3.8.3.1 Stool samples preservation ................................................................................................... 43

3.8.3.2 Irrigation water and hand washing water samples preservation .......................................... 43

3.8.3.3 Soil samples preservation ..................................................................................................... 43

3.9 Detecting of parasites stages in stool, irrigation water, hand washing water, and soil samples 43

3.9.1 Detecting of parasites in stool samples ............................................................................... 43

3.9.1.1 Direct Wet Mount method .................................................................................................... 44

3.9.1.2. Concentration (Sedimentation) method ............................................................................... 44

3.9.1.3. Permanent stained smear (Modified Ziehl-Neelsen Technique (Acid-fast stain)) .............. 45

3.9.2. Detecting of parasites in irrigation water/Hand washing water and Soil samples ............. 46

3.10 Data Entry and Analysis ........................................................................................................... 48

1133 Study Limitations……………. ................................................................................................ 48

CHAPTER IV .................................................................................................................................. 50

Results and Discussion ..................................................................................................................... 50

4.1. Study Participants ...................................................................................................................... 50

4.2. Collected Samples Analysis Results ......................................................................................... 51

4.2.1. Stool, soil, irrigation water (GW), and hand washing water samples analysis results in the

first phase……………………….. ............................................................................................... 51

4.2.2. Stool, soil, irrigation water (GW & TWW), and hand washing water samples analysis

results in the second phase……………. ...................................................................................... 51

4.2.3. Wastewater characteristics through study period: .............................................................. 53

4.3. Parasitic Prevalence................................................................................................................... 54

4.3.3. Parasitic infection prevalence among participants: ............................................................ 54

4.3.3.1. Parasitic infection prevalence in the first phase: ................................................................. 54

4.3.3.2. Parasitic infection prevalence in the second phase: ............................................................ 55

4.3.3.3. Parasitic infection comparison between GWUs and MWUs: ............................................. 57

4.3.2. Prevalence of some parasitic species: .................................................................................... 58

4.3.1. Soil parasitic contamination prevalence: ............................................................................ 59

4.3.1.1. Soil parasitic contamination prevalence in the first phase .................................................. 59

4.3.1.2. Soil parasitic contamination prevalence in the second phase .............................................. 60

4.3.3.3. Relationship between soil samples results and other factors........................................... 61

IX

4.4. Relationship Between Parasitic Contamination In the Collected Samples (Soil, Irrigation

Water, and Hand Washing Water) And Parasitic Infection ............................................................. 63

4.4.1. Relationship between soil parasitic contamination and parasitic infection ........................ 63

4.4.2. Relationship between irrigation water samples and hand washing water results and

parasitic infection…………………… ......................................................................................... 63

4.5 Descriptive Statistics of the Interview Questionnaire ................................................................ 64

4.5.1. Socio-demographic characteristics of the study participants ............................................. 64

4.5.2. Housing characteristics of the study participants ............................................................... 65

4.5.3. Agriculture overview of the study participants .................................................................. 65

4.5.4. Water status of the study participants................................................................................. 67

4.5.5. Sanitation status of the study participants .......................................................................... 68

4.5.6. Birds and animals breeding of the study participants ........................................................ 69

4.5.7. Hygiene behavior of the study participants ........................................................................ 69

4.5.8. Health status of the study participants ................................................................................ 73

4.6 Inferential Statistics of the Interview Questionnaire .................................................................. 76

4.6.1. Socio-demographic factors ................................................................................................. 76

4.6.2. Housing factors……………….. ........................................................................................ 78

4.6.3. Agricultural factors………… ............................................................................................ 79

4.6.3.1. Using TWW in agriculture .............................................................................................. 82

4.6.4.Water status…………….. ................................................................................................... 83

4.6.5. Sanitation status……………. ............................................................................................. 84

4.6.6. Breeding birds and/or animals ............................................................................................ 87

4.6.7. Hygiene behavior…………. .............................................................................................. 87

4.6.7.1 Effect of farmers' hygiene behavior inside home on parasitic infection .............................. 87

4.6.7.1.1 Comparison hygiene behavior inside home between farmer groups: ............................... 88

4.6.7.2. Effect of farmers' hygiene behavior through harvesting on parasitic infection ................... 89

4.6.7.2.1. Comparison of farmers' hygiene behavior '' through harvesting '' .................................... 89

4.6.7.3. Effect of farmers hygiene behavior inside farm on parasitic infection .............................. 91

4.6.7.3.1. Comparison hygiene behavior inside farm between farmer groups ................................. 91

4.6.8. Health status……………. .................................................................................................. 94

4.6.8.1. Relationship between farmers' knowledge and other factors .............................................. 94

4.6.8.2. Relationship between participants those previously had diagnosed and taken helminthic

medicine with parasitic infection ..................................................................................................... 95

4.6.8.3. Relationship between farmers' self-reported symptoms and parasitic infection and hygiene

behavior………………………………….. ...................................................................................... 95

Chapter V ......................................................................................................................................... 97

Conclusions and Recommendations ................................................................................................. 97

X

5.1 Conclusions………………. ................................................................................................... 97

5.2 Recommendations……………. ............................................................................................. 98

5.2.1. Study recommendation…………………………………………………………………..99

5.2.2. Further research recommendations .................................................................................... 99

References ...................................................................................................................................... 100

Annexes .......................................................................................................................................... 108

Abstract (Arabic language)………….. ...................................................................................... 152

XI

List of tables

Table 2.1: Epidemiological characteristics of enteric pathogens against their effectiveness in

causing infections through wastewater irrigation. ........................................................................ 20

Table 3.1 : Medication types that used for treated infected farmers ............................................ 41

Table 4.1: Distribution of the study participants by the source of the used irrigation water ....... 50

Table 4.2 Distribution of the study participants based on samples analysis results in the two

phases………………………….. ................................................................................................. 52

Table 4.3: Wastewater characteristics through study period ........................................................ 53

Table 4.4: Parasitic infection prevalence between farmers group in the first round .................... 55

Table 4.5: Parasitic infection prevalence between farmers in the second round .......................... 56

Table 4.6: Parasitic infection comparison between GWUs and MWUs in the two phases by using

Chi-square…………………………. ........................................................................................... 57

Table 4.7: Prevalence of E. histoltical/dispar/coli in the second round ....................................... 59

Table 4.8: Prevalence of G. lamblia in the second round ............................................................. 59

Table 4.9: Relationship between soil parasitic contamination and irrigation water type in the 1st

phase…………………………… ................................................................................................. 60

Table 4.10: Relationship between soil parasitic contamination and irrigation water type in the 2nd

phase……………………………….. ........................................................................................... 61

Table 4.11: Relationship between soil samples results and other factors .................................... 62

Table 4.12: Relationship between soil samples results and parasitic infection ............................ 63

Table 4.13: Distribution of the study participants by socio-demographic characteristics ............ 64

Table 4.14: Distribution of the study participants by housing characteristics ............................. 65

Table 4.15: Distribution of the study participants by agricultural practices characteristics ......... 67

Table 4.16: Distribution of the study participants by water status characteristics ....................... 68

Table 4.17: Distribution of the study participants by sanitation status characteristics................. 68

Table 4.18: Distribution of the study participants by bids and animals breeding characteristics 69

Table 4.19.1: Distribution of the study participants by hygiene behavior inside \ home

characteristic…………………. .................................................................................................... 70

Table 4.19.2: Distribution of the study Participants by hygiene behavior through harvesting

process…………………………. ................................................................................................. 71

Table 4.19.3: Distribution of the study participants by hygiene behavior through working in farm

characteristic………………………. ............................................................................................ 72

Table 4.20.1: Distribution of the study participants by health status characteristics ................... 74

Table 4.20.2: Distribution of the study participants by farmers' self-reported symptoms ........... 75

Table 4.21: Relationship between socio-demographic factors and parasitic infection ................ 77

XII

Table 4.22: Relationship between socio-demographic factors and hygiene behavior ................. 78

Table 4.23: Relationship between Housing factors and parasitic infection ................................. 79

Table 4.24: Relationship between agricultural factors and parasitic infection............................. 81

Table 4.25: Relationship between agricultural factors and hygiene behavior .............................. 81

Table 4.26: Relationship between period of using TWW in agriculture factors and parasitic

infection…………………………….. .......................................................................................... 82

Table 4.27: Relationship between water status and parasitic infection ........................................ 84

Table 4.28: Relationship between sanitation status and parasitic infection ................................. 86

Table 4.29: Relation between breeding birds and/or animals and parasitic infection .................. 87

Table 4.30: Effect of farmers hygiene behavior inside home on parasitic infection .................... 88

Table 4.31: Comparison hygiene behavior inside home between MWUs & GWUs ................... 89

Table 4.32: Comparison hygiene behavior through harvesting between the two farmer groups

when they use GW………………. .............................................................................................. 90

Table 4.31: Effect of farmers hygiene behavior inside farm on parasitic infection ..................... 91

Table 4.34: Comparison hygiene behavior inside farm between MWUs & GWUs .................... 92

Table 4.35: Comparison MWUs hygiene behavior inside farm through irrigation by GW and

TWW……………………………….. .......................................................................................... 93

Table 4.36: Relationship between farmers' knowledge and other factors .................................... 94

Table 4.37: Relationship between participants those previously had diagnosed and had taken

helminthic medicine and parasitic infection ................................................................................. 94

Table 4.38: Association between farmers' self-reported symptoms and hygiene behavior.......... 96

XIII

List of figures

Figure (2.1): S. stercoralis life cycle ............................................................................................ 24

Figure (2.2): A. lumbricoides life cycle ....................................................................................... 26

Figure (2.3): Cryptosporidium life cycle ...................................................................................... 27

Figure (2.4): E. histolytica Life cycle .......................................................................................... 29

Figure (2.5): G. lamblia life cycle ................................................................................................ 30

Figure (2.6): Microsporidia life cycle .......................................................................................... 32

Figure (4.1): Study participants distribution ................................................................................ 50

Figure (4.2): Multiple and single infection at the infected participants in the two study phases . 53

Figure (4.3): Parasitic infection at the first phase ........................................................................ 54

Figure (4.4): Parasitic infection at the second phase .................................................................... 55

Figure (4.5): Parasites prevalence in stool samples at the two phases. ........................................ 56

Figure (4.6): Parasitic contamination in soil, irrigation water, and hand washing water samples at

the first phase…………………. .................................................................................................. 60

Figure (4.7): Parasitic contamination in soil, irrigation water, and hand washing water samples at

the second phase……………….. ................................................................................................. 61

XIV

List of annexes

Annexes .......................................................................................................................................... 108

Annex (1): Wastewater networks in the Gaza Strip ................................................................... 108

Annex (2): Pathogens levels and diseases associated with untreated wastewater ...................... 108

Annex (3): Survival times of selected excreted pathogens in soil, wastewater and on crop

surfaces at 20-30oC…………… ................................................................................................ 109

Annex (4): Wastewater reuse guidelines .................................................................................... 109

Annex (5): Location of Sheikh-ejleen pilot project area ............................................................ 112

Annex (6): Post wastewater treatment system layout, source .................................................... 112

Annex (7): Interview questionnaire with consent form .............................................................. 113

Annex 7a: Interview questionnaire with consent form (English version) .................................. 113

Annex 7.b: Interview questionnaire with consent form (Arabic version) ................................ 125

Annex (8): Expert Names who validated the interview questionnaire ....................................... 132

Annex (9): Helsinki Committee Approval Letter....................................................................... 133

Annex (10) : Stool analysis report for medical treatment .......................................................... 134

Annex (11) : Medicine prescriptions .......................................................................................... 135

Annex (12): Comparison between parasitic infection and contamination by figures ................ 136

Annex (13): Parasities detected in the collected samples ........................................................... 138

Annex (14): Relation between Age variable and other variables ............................................... 151

XV

List of abbreviations

BOD Biochemical oxygen demand

CDC Centers for Disease Control and Prevention

CMWU Costal Municipality Water Utility

CSO-G The Comparative Study of Options for an Additional Supply of Water

for the Gaza Strip

EC Electrical conductivity

FAO Food and Agriculture Organization

FG Farmer's group

GS Gaza strip

GW Groundwater

GWIP Groundwater irrigation periods

GWUs Groundwater users

GWWTP Gaza wastewater treatment plant

HB Hygiene behavior

hr. Hour

JCP Job Creation Program

Km Kilometer

M3/d Cubic meter per day

MCM/y Million cubic meter per year

Mg/l Milligram per liter

MID Minimal infective dose

Min Minute

Ml Millimeter

Mm3 Million cubic meter

MOA Ministry of Agriculture

MOH Ministry of Health

MW Mixed water

MWUs Mixed water user

OR Odds ratio

PCBS Palestinian Central Bureau of Statistics

pH Power of hydrogen

PHG Palestinian Hydrology Group

PHIC Palestinian Health Information Center

PI Parasitic infection

XVI

PWA Palestinian Water Authority

RII Relative importance index

SAT soil-aquifer treatment system

Sec/s Second

SSR Statistically significant relationship

TSS Total suspended solids

TWW Treated wastewater

TWWIP Treated wastewater irrigation periods

UNDP United Nations Development Programme

UNEP United Nations Environment Programme

UNRWA The United Nations Relief and Works Agency

US EPA United States Environmental Protection Agency

USAID United States Agency for International Development

WB World Bank

WFP World Food Programme

WHO World Health Organization

WW wastewater

WWR Wastewater reuse

WWTP Wastewater treatment plant

1

Chapter I

Introduction

1.1 Background

Gaza strip (GS) is located in a semi-arid region, with a tight area of 365km2; population of the

Gaza strip is more than 1.8 inhabitant and will reach more than 2.6 Million inhabitant by year

2025 (CMWU, 2016; Dudeen, 2001). Groundwater aquifer is considered the main water

supply source for all kind of human usage in the Gaza Strip (domestic, agricultural and

industrial). This source has been faced a deterioration in both quality and quantity for many

reasons such as the low rainfall, increasing the urban areas which led to a decrease the

recharge quantity of the aquifer, also increasing the population number which depletes the

groundwater aquifer and lead to seawater intrusion in some areas as a result of pressure

differences between the groundwater elevation and sea water level (CMWU, 2016). Recent

reports showed that the groundwater aquifer in the GS will become unusable by 2020 as the

deterioration will become irreversible (United Nations Country Team in the occupied

Palestinian territory, 2012).

The present net aquifer balance is negative; the net deficit is about 85 MCM/y and will

increase if there is no management actions taken (PWA, 2016). In the same time food security

levels in 2012 year has collapsed in Gaza, and became only one in ten households are food

secured (PCBS et al., 2012).

Water resource planners therefore, proposed to use non-conventional alternate sources of

water to bridge the deficits (Al-Agha & Mortaja, 2005). Possible management options include

the use of treated wastewater (TWW) and desalination are at the forefront of water

management plans (Al-Juaidi et al., 2011; Mimi et al., 2007).

There is a high potential for wastewater reuse (WWR) due to the increased generated

wastewater quantities, about 92Mm3 of wastewater were estimated to be generated in GS by

year 2020 (Afifi, 2006). This amount if properly used can provide adequate amount for the

agricultural sector and save the aquifer from further deterioration. WWR not only can reduce

the water deficit in the GS, but it also can minimize the environmental deterioration which is

one of the main aspects considered by the policy makers in the GS (Al‐ Juaidi et al., 2010).

2

1.2 Problem Statement

Wastewater (WW) incresingly used for agriculture in both developing and industrilized

countries as a result of (a) Increasing water scarsity, stress and degrgation of fresh water

resources resulting from improper disposal of wastewater. (b) Population increase and related

increasing demand for food. (c) Agrowing recognition of the resource value of wastewater and

the nutrients it contains. (d) Ensuring environmental sustainability and elmination poverty and

hunger (WHO, 2006). WW contains a varity of different pathogens, may of which are capable

of survival in the environment (in the wastewater, on the crops, or in the soil) long enough to

be transmitted to human. In places where wastewater is used without adequate treatment, the

greatest heath risks are usually associated with intestinal helminths (WHO, 2006). The health

hazards associated with wastewater use in irrigation are of three kinds: (a) The rural health and

safety problem for those working on the land where the wastewater is being used (farmers

workers and their families), (b) Population groups consuming crops irrigated by treated

wastewater, and (c) Health effects among population residing near wastewater-irrigated fields

(Shuval, 1990). Health risk associated with wastewater reuse may differ in different subgroups

of the population. The most important subgroup to consider are agricultral workers exposed

occupationaally (occupational risk) and persons consuming crops irrigated with the

wastewater (consumer risk) (WHO, 1989). Many studies reported the parasitic risk from

WWR between farmers. In Pakistan it was reported that farmers who using wastewater in

irrigation were five times more likely to be infected with hookworms than others using canal

water (Ensink et al., 2005). In Senegal where only WW is available 60% of farmers were

infected with intestinal helminths (Faruqui et al., 2006). Uganda farmers who exposed to WW

were more likely to be infected with helminths than slum dwellers and workers involved in

sludge collection (Fuhrimann et al., 2016).

As we see, parasitic infection between farmers who use TWW in agriculture is a known public

health issue in the world, but not studied yet in GS. This study is a Pioneer study will

investigate the parasitic infection among farmers dealing with TWW in Al-Zaitoun area, Gaza

City in order to submit suitable recommendations that could be helpful for decision makers to

take the necessary measures in order to reduce the possible infection and protect the health of

farmers and their families who involved or will be involved in future in WWR projects.

3

1.3 Problem Justification

The agricultural sector represents a key source of income for Gaza at the present time.

However, it suffers from inefficiencies and from the profligate and uncontrolled use of the

precious water supplies; approximately half of the current fresh water use in Gaza is allocated

to the agricultural sector. Strategic studies that completed by the Palestinian water Authority

(PWA) and assessments by both the World Bank (WB) and United Nations Environment

Programme (UNEP) have all shown that the water supply situation in Gaza is in an extreme

concern at present, and will become much worse over time, in the absence of major

interventions. Reuse of treated wastewater was a very important component of water strategy

as revealed by the comparative study of options for an additional supply of water for the Gaza

Strip (CSO-G), in part because approximately half of the current fresh water use in Gaza is

allocated to the agricultural sector (Phillips Robinson & Associates, 2011).

PWA strategic planning study in 2000 sets out strategy to increase the wastewater reuse over

the next 20 years. According to PWA plans, 60% of the available TWW will be reused for

agricultural purpose in the west Bank and Gaza (39 MCM and 51MCM respectively) and 15%

will be recharged to aquifer (10 MCM and 13MCM respectively) (World Bank, 2004).

As recommend in CSO-G; the reuse of treated wastewater should be introduced immediately

on a pilot scale, with the intention to prove the value of this to the farming community; the

pilot reuse projects should be followed as soon as possible by large-volume reuse of treated

wastewater, as this intervention is especially important in reducing groundwater abstraction

and hence in protecting the aquifer in the long term. A number of wastewater reuse

demonstration or pilot projects have been established in Gaza, and numerous studies related to

WW treatment and reuse also have been conducted; these were vary from guidelines to

preferred technology and social acceptability reports, and it may be considered that Gaza has

long ago passed the ‗trial‘ stage and is ready for much larger-scale WWR than currently exists

(Phillips Robinson & Associates, 2011). However there is no studies to investigate the

epidemiological link between this practice and parasitic infection among farmers. In this

regard this study aimed to determine the association between using TWW in agriculture and

the parasitic infection in the second pilot project at Al-Zaitoun area, Gaza.

4

1.4 Objectives

1.4.1. Main objective:

The main objective of this study is to investigate the parasitic infection among farmers dealing

with treated wastewater in Al-Zaitoun area, Gaza City.

1.4.2. Specific objectives:

1. To compare the parasitic infection prevalence between farmers dealing with treated

wastewater after using TWW in irrigation for three months and farmers dealing with

groundwater (as a benchmark for comparing).

2. To examine the parasitic status for treated wastewater, groundwater, soil, and farmers hand

washing water.

3. To identify the risk factors associated with parasitic infection especially the hygiene

behavior among the farmers.

1.5 Context of Study

This study conducted at two agricultural areas in Gaza city where influenced by many

demographic, socioeconomic, environmental, and health factors.

1.5.1. Demographic and Socio- economic Context

Gaza Strip is a coastal region located in the southern part of Palestine. GS divided into five

governorates: North, Gaza City, Middle area, Khanyouins area, and Rafah area. At mid of

2016 the estimated population of Gaza Strip totaled 1.88 million of which 956 thousand males

and 925 thousand females (PCBS, 2017).

The Gazan economy has come to a near standstill due to a combination of unemployment,

closures, and restrictions placed on workers, industries, goods and services. With

unemployment in Gaza reaching alarmingly high levels, the military operations have further

paralyzed economic development, destroying much of the remaining productive resources,

capital stock, and employment opportunities. The Gazan economy is largely dependent on

agriculture, however due to closures and land razing, this sector has been greatly affected. In

addition to the military operations have been increased food insecurity and loss of livelihoods,

demolition of greenhouses and agricultural infrastructure, uprooting of trees, contamination of

agricultural land, loses in livestock, and widespread damage to crops (UNDP, 2012).

5

1.5.2. Environmental and health factors

Water quality monitoring has revealed very high chloride and nitrate pollution in coastal

aquifer. High nitrate levels are primarily caused by the infiltration of sewage into water

resources, as well as by over application of N-Fertilizers. High chloride concentration are

primarily caused by the sea water intrusion. Although environmental conditions are difficult

in GS as a result of the very high population density, sanitary conditions have much improved

over the last few decades. As a result of this improving life expectancy has risen, infant

mortality has decreased and most health indicators are become among the best in the region.

An important achievement of the health sector in Palestine was the serious drop in child

mortality due to poor quality water and poor sanitation (PWA, 2013).

1.6 Operational Definitions (MED WWR WG, 2007)

Groundwater

Water contained in rocks and sub soils.

Irrigation water

Appropriate quality of water suitable for irrigation application not result in any significant risk

to health of user or consumer.

Reclaimed water

Municipal wastewater that has been treated to a specific water quality criteria, normally a

higher quality than secondary treatment, so it can be beneficially reused.

Restricted irrigation

The use of treated wastewater to irrigate all crops except salad crops and vegetables that may

be eaten uncooked.

Unrestricted irrigation

The use of treated wastewater to irrigate crops that are normally eaten raw.

Treated wastewater

Primary treated wastewater, secondary treated wastewater, tertiary treated wastewater, or to a

higher standard.

6

Treated wastewater reuse

Beneficial use of appropriately treated wastewater.

Wastewater

Liquid waste discharged from homes, commercial premises, and similar sources to individual

disposal systems or to municipal sewer pipes, which contains mainly human excreta and used

water. When wastewater produced mainly from household and commercial activities, it is

called domestic, municipal wastewater, or domestic sewage.

Soil aquifer treatment

An infiltration of the sewage effluent into the aquifer, and the natural movement of the

effluent within the groundwater acts as a natural filter to treat wastewater (Austrian

Development Cooperation & Palestinian Water Authority, 2011).

7

Chapter II

Literature Review

This chapter illustrates the study conceptual framework and describes background information

about water, wastewater status in Gaza strip and agricultural sector; in addition it describes

the interest and effect of wastewater reuse, previous experience of treated wastewater reuse in

Gaza Strip, health risks associated with treated wastewater irrigation, microbial contaminants

in wastewater, chain of infection, major parasites that causing waterborne parasitic diseases,

health protection measures for reducing health risks associated with wastewater irrigation, and

the treated wastewater reuse guidelines.

2.1 Conceptual Framework

Farmer factors: Age Sex

Health status Hygiene behavior

Working years

Pathogen factors: Infective dose

Species strain DIM

Survival in environment

Periodic

monitoring and

following up from

the responsible authorities and

institutions

Parasites transmission

route for farmers

Farmers response

Stool

samples

Farmer‘s

parasitic

infection

investigation

Working in

agriculture

may expose

farmers to parasitic

infection

Investigation of parasites load in the

transmission routes

Soil samples Hand washing water TWW / GW samples

Farmer‘s factors

investigation

Questionnaire

Parasitic

infection

Agricultural activities

Soil

Hand , Person to

Person

Irrigation water

Transmission

(infection with

manifest (sickness

Transmission

(symptomless

(infection

No transmission Farmers use/deal

with TWW as

irrigation source

Farmers deal with GW. as irrigation

source (as a control group)

8

Human enteric disease are caused by many types of pathogenic microorganisms including

bacteria, viruses, protozoa, and helminths. These diseases are transmitted when the pathogenic

microorganisms are excreted to the environment by an infected person "host", transported by a

suitable vector; such as water or food, and ingested by another susceptible human "host".

Large numbers of the disease-causing pathogens are excreted in the urine and feces of infected

individuals; thereafter these pathogens contaminate the wastewater which dumped into the

environment or agricultural lands when farmers use TWW in irrigation. The number of

pathogenic microorganisms per gram feces of infected person usually ranges from 1 million to

100 million (106-10

8) of bacteria or viruses, from 10 to 100 thousand (10-10

5) of protozoa, and

100 to 10,000 (102-10

4) of encysted helminths. Wastewater from communities carries the

pathogenic microorganisms excreted by the diseased and infected people who live in that

communities. The calculated amount of pathogenic microorganisms in the wastewater stream

is many millions per liter for bacteria, thousands per liter for viruses, and a few hundred per

liter for some of the helminth eggs (Shuval, 1990).

Based on the epidemiological studies the using TWW in agriculture exposes farmers to the

pathogenic microorganisms still exist in the WW after treatment; the pathogenic

microorganisms can transmit to farmers either from the TWW itself, soil, contaminated plants,

or from other infected farmer/person.

Many factors play significant role in determining farmers response, some of these factors are

related to farmer as age, sex, health status, hygiene behavior, working years in agriculture or

related to the pathogenic microorganisms itself as species, infective dose, survival in

environment.

The periodic monitoring and following up TWWR projects by the responsible

authorities/institutions such as Ministry of Health (MOH), PWA, or Coastal Municipality

Water Utility (CMWU) should ensure farmers commitment in using protection tools and the

provided TWW quality is according to TWWR standards.

In this study stool samples were taken in order to investigate the parasitic prevalence, while to

investigate the parasitic load in the surrounding environmental mediums irrigation water, soil,

and hand washing samples were taken, finally to find the relationship between risk factors and

parasitic infection interview questionnaire was conducted.

9

2.2 Water Status in Gaza Strip

The population of the Gaza Strip is more than 1.8 inhabitant and will reach more than 2.6

Million inhabitant by year 2025. Groundwater is considered the main water source that supply

Gaza Strip population by domestic, agricultural, and industrial water needs. Gaza coastal

aquifer is limited where its thickness is between120-150 meter in some areas of the western

part to few meters in the east and southern part of the coastal aquifer. It has been faced

deterioration in both quality and quantity for many reasons such as the low rainfall rate,

increasing the urban areas which led to a decrease in the recharge quantity, increasing the

population who depletes the groundwater and lead to seawater intrusion in some areas, and

existing incorrectly designed sewage system (CMWU, 2016).

According to PWA reports the total abstraction of GW is a proximately 190.5 MCM/y, from

which 95.202 MCM/y for domestic use through 260 water wells, Mekorot, and 154

desalination plants. The total water supplied for agriculture use including the livestock are

about 95.3 MCM/y (92.7 for agriculture and 2.64 for livestock). The present net aquifer

balance is negative, the net deficit was about 85 MCM/y and will increase if there is no

management actions taken (PWA, 2016).

In Gaza strip, the direct consequences of over pumping of the coastal aquifer are seawater

intrusion and uplift of the deep brine water; consequently, the water quality became fall below

the accepted international guidelines for potable water resources. Currently, several

agricultural wells are also showing high salinity levels. In addition to salinity problem Gaza is

experiencing a serious wastewater-driven problems, it is characterized by high levels of

nitrates in the GW. The chloride concentration of the pumped water is in the range of 100-

1000 mg/l, while the nitrate is in the range of 50-300 mg/l. As a result there is only less than

5% of the delivered domestic water matching prevailing drinking water Standards (PWA,

2012).

Regarding microbiological water quality, El-Mahallawi (1999) and Melad (2002) (as cited in

(Yassin et al., 2006)) reported that despite of there are few studies have addressed

microbiological water quality problem, it has deteriorated in the Gaza strip. The

bacteriological quality of the tap water and the roof tanks in Deir El-Balah - Gaza strip are not

hygienically safe. Various levels of total and fecal coliforms have also been found in water

10

samples from 20 groundwater wells located around the wastewater treatment pond of Beith

Lahia - Gaza strip. Another study found a total of 8 out of 420 samples (1.9%) of various

drinking water sources which collected during one year period in Gaza strip are contaminated

by Cryptosporidium oocysts (Ghuneim & Al-Hindi, 2016). In addition to it was found the

total and fecal coliform contamination in both water wells and networks generally exceeded

the WHO limit in Gaza Governorate. A strong correlation (r = 0.7) was found for giardiasis

with fecal coliform contamination in drinking water networks, whereas correlation with

diarrheal diseases and hepatitis A were relatively weak (r = 0.3 and 0.1, respectively).

Diarrheal diseases were the most self-reported diseases in Gaza city; such diseases were more

prevalent among people who used municipal water than people who used desalinated water

and home filtered for drinking (OR=1.6) (Yassin, et al., 2006).

2.3 Wastewater Status in Gaza Strip

2.3.1. Wastewater networks in the Gaza strip:

Sanitation sector in GS over the previous years was, to some extent, neglected and this is due

to the frequent closures of Gaza crossing in addition to the limited funding for sanitation

sector. The expansion of wastewater networks is linked to the treatment plants where the

dumped water is treated. Treatment plants have barely obtained some funds for expansion,

developing and improving their efficiency. Thus, the network coverage of this sector has

reached 72% distributed amongst the Gaza strip governorates (CMWU, 2016) as shown in the

Annex (1).

2.3.2. Wastewater treatment plants in Gaza strip:

In Gaza strip there are three main wastewater treatment plants (Beit Lahiya treatment plant,

Sheikh Ajleen ''Gaza'' treatment plant, and Rafah treatment plant) and two temporary plants

(Khanyounis temporary treatment plant and Wadi Gaza intermediate treatment plant) for

collecting and treating wastewater to the level allowed to be dumped to the sea and to not

pollute the aquifer in case of infiltration. The locations of these treatment plants were chosen

during the times of the Israeli occupation of the Gaza strip; however, the regional contour of

Ministry of Planning suggests establishing three central treatment plants near the eastern

armistice line. The current treatment plants still do not meet the standards of treating

wastewater in Gaza and this is due to the frequent closure of Gaza crossings that hinder the

11

required periodical maintenance. Moreover, the population growth without a proper

expansion of the treatment plants has caused a problem since the wastewater production rate is

increasingly (CMWU, 2016).

2.3.3.1. Gaza wastewater treatment plant (GWTP):

GWTP was established in 1979 with an infiltration basin next to it. By the year 1986 UNDP

established another two infiltration basin to develop the plant. The plant also was developed in

1996 by the Municipality of Gaza and The United Nations Relief and Works Agency

(UNRWA) in order to recharge 12,000 cubic meters per day. United States Agency for

International Development (USAID) in collaboration with PWA in 1998 rehabilitated the

plant and enlarge its capacity to recharge 35,000 cubic meters per day in order to

accommodate population growth till the year 2005, then a part of the treated WW was pumped

to the infiltration basins and another part was pumped to the sea. After the year 2005 many

people seized the plant infiltration basins and turned them into agricultural lands. In 2009 the

water pumped to the plant increased to 60,000 cubic meters per day and this exceeds the plant

capacity (CMWU, 2016).

2.4 Agriculture

2.4.1. Irrigation water quantity in Gaza strip:

Irrigated agriculture is a vital component of total agriculture and supplies many of the food

needs for human beings and animals. There are about 2600 agricultural legal wells and more

than 7765 illegal agricultural wells distributed allover Gaza Strip (Al-Daddah, 2013).

Approximately half of the current fresh water use in Gaza is allocated to agricultural sector

(Phillips Robinson & Associates, 2011). The amount of fresh water allocated for agriculture

should be reduced radically to meet the increasing demand for the municipal purposes. So it is

becoming clear that developing new water sources will not be enough to meet these

challenges; it must be coupled with wiser use of existing sources of water through water

demand management measures, water reuse, and maintenance of water quality. Adequate

water demand management in the agricultural sector needs establishment of incentives,

regulations and restrictions help, guide, and coordinate the farmers' behavior for the efficient

use of water in irrigation while encouraging water saving technologies (Al-Daddah, 2011).

12

2.4.2. Irrigation water quality in Gaza strip

The main water source for irrigation in GS is the coastal aquifer who has many water quality

problems; approximately two-thirds of the total cultivated area in Gaza were irrigated.

Moreover the rainfall is insufficient for the cultivation of most crops and supplementary

irrigation is needed in order to meet the crop water requirements. In spite of the over

extraction from aquifer has resulted in draw down the groundwater with resulting intrusion of

seawater and up-coning the underlying saline water. The irrigation process can degrade water

quality by increasing salt concentration and adding toxic materials through the over

application of fertilizers and mismanagement of pesticides (Al-Daddah, 2011).

2.4.3. Future water resources development for agriculture in the Gaza strip

In light of the expected climate change in the region, and upon the fact that the entire existing

agricultural demand is taken from the groundwater aquifer, which a large proportion of this is

brackish. PWA has reported that by 2020 the utilization of wastewater is planned to provide

50 % of the total required by agriculture, with the remainder being provided by the freshwater

aquifer in order to maintain the balance of salts in the soil and provide the quality necessary

for certain crops (PWA, 2010).

2.5 Interest in Wastewater Reuse in the World

Wastewater treatment and disposal through land application gained increasing attention after

1945 provided almost the only feasible, relatively low-cost method for sanitary disposal of

municipal wastewater as a mean of preventing surface water pollution and increasing water

resources in arid and semiarid areas. These factors coupled with rapid urban growth and the

need to increase agricultural production made sewage farms attractive to the agricultural

community and municipal planners. The regulations developed by the state of California

helped to re-establish the feasibility of wastewater reuse in agriculture in the western part of

the United States. Soon thereafter a similar trend began in many of the rapidly developing

countries faced water shortages and insufficient waterways to properly dilute and dispose of

municipal wastewater (Shuval, 1990).

A survey of current wastewater reuse practices in developing countries carried out by the WB

and UNDP has estimated that approximately 80 percent of the wastewater flow from urban

13

areas in developing countries is currently used for permanent or seasonal irrigation

(Gunnerson 1985). Although wastewater reuse has been practiced more widely in developing

countries over the past thirty years, much of it is unplanned and uncontrolled and poses a

threat to public health. These risks must be fully understood and appropriate measures must be

taken to provide technically feasible and economically attractive solutions so that the public

can reap the full benefits of wastewater reuse without suffering harmful effects (Shuval,

1990).

2.6 Previous Experiences of Treated Wastewater Reuse in Gaza Strip

Responding to the short-term strategy of PWA in 2000, many small wastewater reuse pilot

projects carried out in Gaza strip. These experiments aimed principally to demonstrate the

practical feasibility of treated wastewater for agricultural purposes in a sustainable

development and to increase farmers and the public awareness that the agricultural reuse of

treated wastewater is acceptable and feasible in terms of good production, minimum health

risks, and good economic results (Austrian Development Cooperation & Palestinian Water

Authority, 2011).

There are four reuse pilot projects in GS demonstrated to use treated wastewater for irrigation

fodder and fruit orchards. Some pilot projects used the soil-aquifer technique to treat the

sewage water before being used for irrigation, and another pilot projects used sand filters.

2.6.1. Bedouin village pilot project:

The first pilot location for TWWR was at Beit Lahia by Italian fund; the effluent of the Beit

Lahia Lake water treatment was used to irrigate the fodder crops (alfalfa, Sudan grass, and ray

grass). The fodder crops were used for feeding the small animals. The total area that cultivated

by Alfalfa is extended to 45 dunums and later on enlarged to 140 dunums. A comprehensive

monitoring system is carried out to examine crops, soil, ground water, and the effluent from

Beit Lahia Lake water treatment. Short training courses for farmers as well the agricultural

engineers to qualify the target groups in addition to public awareness sessions for the

interested farmers and agricultural associations was lunched (Austrian Development

Cooperation & Palestinian Water Authority, 2011).

14

2.6.2. Zaitoun area pilot project:

The second pilot location for TWWR was in 2004. The Job Creation Program (JCP) in

cooperation with Palestinian Hydrologists Group (PHG) had proposed a project to use treated

wastewater from (GWWTP) for irrigating 100 dunums of citrus and olive trees at A-Zaitoun

area. The project had been established under French fund and the supervision of PWA and

Municipality of Gaza with coordination with Ministry of Health (MOH) and Ministry of

Agriculture (MOA). This project was successful, thereafter, extension has made till the last

Israeli invasion that led to the destruction of some of infrastructure of the project. However,

rehabilitation was currently done under the French and Spanish funds and the project was

operated again on November 2010 covering 186 dunums (Al-Dadah, 2013) .

2.6.3. Al-Mawasi ( SAT):

JCP in close cooperation with PWA and CMWU with a fund of the Catalan Government

launched the third pilot location for TWWR with soil-aquifer treatment system (SAT). The

project started with 60 dunums in 2008 and expanded to 90 dunums in 2010 cultivated with

Jawaffa and Palm trees (Al-Dadah, 2013).

2.6.4 European hospital in Khanyounis project:

The fourth pilot location for TWWR was funded by the European Commission, and was

installed in the European hospital in Khanyounis. The effluent from the plant is irrigating (by

sprinkler) 90 dunum of olive, and other trees. The main partners involved are MOA and PWA

(Austrian Development Cooperation & Palestinian Water Authority, 2011).

2.7 Effects of Wastewater Reuse in Agriculture

2.7.1. Positive effects of treated wastewater use in agriculture:

2.7.1.1. Environmental benefits:

Wastewater reuse schemes if managed well can have several environmental benefits as a)

Avoidance of surface water pollution, which would occur if the wastewater were not used but

discharged into surface water, b) Avoidance major environmental pollution problems, such as

dissolved oxygen depletion, eutrophication, foaming, and fish killing, c) Conservation or more

rational use of freshwater resources, especially in arid and semi-arid areas, d) Reduced

requirements for artificial fertilizers, with a concomitant reduction in energy expenditure and

15

industrial pollution elsewhere, and e) Soil conservation through humus build-up and through

the prevention of land erosion, desertification control and desert reclamation through irrigation

and fertilization of tree belts (D Mara & S Cairncross, 1989).

2.7.1.2. Agricultural benefits:

Wastewater reuse schemes if managed well can have several agricultural benefits as reliable

and possibly less costly irrigation water supply, a) Increased crop yields, often with larger

increases than with freshwater due to the wastewater‘s nutrient content, b) Ensuring more

secure and higher urban agricultural production, c) Contribution to food security, income and

employment generation in urban areas, and d) Improving livelihoods for urban agriculturalists,

many of whom are poor subsistence farmers, including a large share of women (Scheierling et

al., 2010). Wastewater can often contain significant concentrations of organic and inorganic

nutrients for example nitrogen and phosphate. There is potential for these nutrients present in

recycled water to be used as a fertilizer source when WW is recycled as an irrigation source

for agriculture, in addition to soil microorganisms have been observed to have increased

metabolic activity when sewage effluent is used for irrigation (Ramirez-Fuetes et al. 2002,

Meli et al. 2002).

2.7.1.3 Water resources management benefits:

In terms of water resources management, the benefits may include supplying: a) An

additional drought-proof water, often with lower cost than expanding supplies through

storage, transfers, or desalinization; b) More local sourcing of water; inclusion of wastewater

in the broader water resources management context; and c) More integrated urban water

resources management (Scheierling, et al., 2010).

2.7.2 Negative effects of treated wastewater use in agriculture:

2.7.2.1 Environmental impacts:

Sewage effluents from municipal origin are rich in organic matter and also contain appreciable

amounts of major and micronutrients (Brar et al., 2000; Pescod, 1992). However, these

chemical constituents may affect public health and/or environmental integrity (Assadian et al.,

2005). The wastewater may also contain significant quantities of toxic metals (Som et al.,

1994; Yadav et al., 2002) and therefore its long-term use may result in toxic accumulation of

heavy metals with unfavorable effects on plant growth (Rattan et al., 2005). In addition to

16

reuse of wastewater may be seasonal in nature, this will resulting in the overloading of

treatment and disposal facilities during the rainy season. In some cases, reuse of wastewater is

not economically feasible because of the requirement for an additional distribution system.

Also the application of improper treated wastewater as irrigation water or as injected recharge

water may result in groundwater contamination (Austrian Development Cooperation &

Palestinian Water Authority, 2011).

2.7.2.2 Agricultural impacts:

The practice of wastewater reuse could result in soil damage. Although the organic matter in

wastewater can help improve soil texture and water-holding capacity, wastewater also has

harmful effects by causing soil salinization, blocking soil interstices with oil and grease, and

accumulating heavy metals (Faruqui et al., 2004) There is a concern about a possible increase

in soil-borne diseases in human populations (Santamaria & Toranzos, 2003).

Many of the diseases associated with soils have been well characterized and studied, enteric

diseases and their link to soil contamination have been understudied and possibly

underestimated (Solaymani-Mohammadi et al., 2010).

2.8 Health Risks Associated with Treated Wastewater Irrigation

Wastewater use in agriculture has risk especially when untreated wastewater is used for crop

irrigation, it poses substantial risks not only to the farmers, but also the surrounding

communities and the consumers of the crops. The microbial risk is the biggest risk to health

which arises as a result of existence pathogens that are usually present in untreated or partially

treated (and to some level also in treated) wastewater (Asano, 1998). People who directly or

indirectly work by using WW have potentially greater risk for parasitic infection than the

general population (Zimmerman, 2005).

The detection of pathogens in soil, wastewater used for irrigation and on crops indicates

potential environmental and health risks to occupationally exposed farmers and consumers of

the contaminated crops. As there are soil-borne diseases caused by enteric pathogens which

get into soil by means of human or animal excreta (Weissman et al., 1976).

17

2.8.1 Risks to agricultural workers and their families:

Direct contact with untreated wastewater in irrigation at particularly in the dry season causes

diarrhoeal disease; the risk of diarrhoeal disease reduced when the wastewater is stored in

storage reservoirs before use (Blumenthal et al., 2001; Cifuentes, 1998). There is also

evidence to suggest that direct contact with untreated wastewater can lead to increased

helminth infection mainly Ascaris and hookworm infection and that this effect is more

pronounced in children than in adult farm workers (Blumenthal, et al., 2001; Bouhoum &

Schwartzbrod, 1998; Habbari et al., 2000; Peasey, 2000).

Study in Mexico revealed that the irrigation with untreated or partially treated wastewater was

directly responsible for 80% of all Ascaris infections and 30% of diarrhoeal disease in farm

workers and their families (Cifuentes et al., 2000). The hookworm infection effect of exposure

to untreated wastewater among farm workers varies from attributable risks of between 37% in

children and 14% in adults (Krishnamoorthi et al., 1973). The major threat to farmers and

their families is from intestinal parasites most often worms (Faruqui, et al., 2004). Bacterial

and viral infections are other health threats which can occur after the consumption of raw

vegetables contaminated with fecal matter. Cholera epidemic in Jerusalem and typhoid

epidemics in Santiago and Dakar are all isolated to urban and peri-urban agriculture (UPA)

(Faruqui, et al., 2004). Study conducted in Phnom Penh, Cambodia indicated that there may be

an association between exposure to wastewater and skin problems such as contact dermatitis

(eczema) (Van der Hoek et al., 2005).

2.9 Wastewater Microbial Contamination

The principal categories of pathogenic organisms found in wastewater are bacteria, viruses,

protozoa, and helminths (Pescod, 1992). The numbers and types of pathogens found in

wastewater vary both spatially and temporally depending on season, water use, economic

status of the population, disease incidence in the population producing the wastewater,

awareness of personal hygiene, and quality of water or food consumed (WHO, 2006).

Examples of Microbial Pathogen levels and diseases associated with untreated wastewater are

shown in Annex (2).

18

2.9.1 Wastewater pathogenic parasites:

A parasites is an organism that lives on or in another species which constitute the host. The

parasites normally doesn‘t kill its host, because the life of the parasites also would be

terminated (Zimmerman, 2005). Parasites are two types:

2.9.1.1 Helminthes parasites:

There are two groups of helminths. These groups are the flatworms and roundworms.

Flatworms consist of tapeworms (cestodes) and flukes (trematodes). Roundworms also are

known as nematodes. Helminths exist in two forms. The first form is an actively growing larva

or worm. The larva is found inside the definitive host and produces eggs or ova. The egg or

ovum is the second form and leaves the host in fecal waste. The ovum develops a protective

structure that is resistant to adverse conditions and has the ability to infect a new host

(Zimmerman, 2005). Helminths can be present as the adult organism, larvae, eggs, or ova. The

eggs and larvae, which range in size from about 10 μm to more than 100 μm, are resistant to

environmental stresses (EPA, 2012). Intestinal nematodes are the greatest health risk involved

in the use of untreated wastewater in agriculture (Mitchell, 1992), the helminths that are of

significant health risk, include round worm (Ascaris lumbricoides), the hook worm

(Ancylostoma duodenale or Necator americanus), the causative agent of strongyloidiasis

(Strongyloides stercoralis), and the whip worm (Trichuris trichiura) (Ottoson, 2005; Toze,

1997).

2.9.1.2 Protozoan parasites:

The term ―protozoan‖ is a common name of single-celled, eukaryotic organisms that are either

animal-like, fungus-like, or plant-like. Protozoans also can be distinguished or grouped by

their inability or ability to move with cilia (ciliates), flagella (flagellates), or pseudopodia

(amoebae). Protozoans that have no direct locomotive ability are coccidians. The form of a

protozoan parasite that lives inside the host is called the trophozoite stage (Zimmerman,

2005). Most of the protozoan parasites produce cysts or oocysts, which are quite resistant to

environmental stress and to disinfection which are able to survive outside their host under

adverse environmental conditions. A new trophozoite is released from the cyst. This process is

called excystment (Bitton, 2005).

19

Although most protozoans are free living in soil or water, some protozoans can be parasitic.

Parasitic protozoans are small in size (2–200mm). The animal-like protozoans contain several

parasites of concern to wastewater personnel including Cryptosporidium (Zimmerman, 2005).

Erdogrul and Sener 2005 as cited in (Kwashie, 2011) reported that the protozoa parasites

commonly detected in wastewater and wastewater irrigated fields are the Giardia lamblia,

Enterobius vermicularis, Entamoeba histolytica, and Cryptosporidium parvum.

2.9.2 Survival of parasites in environment:

The persistence or survival of pathogenic microorganisms, and their resistance to treatment

processes is an important wastewater reuse issue (Toze, 1997).

Pathogenic microorganisms remain a health risk as long as they persist in environments such

as wastewater. The longer they survive in an environment the greater the potential they have

of becoming mobilized if the chemical, physical or hydraulic conditions are suitable.

Therefore, the longer pathogens persist in wastewater, the chance that they could come into

contact with workers and the general public increase (Kwashie, 2011).

Knowledge of the survival of pathogens in soil and on the crop allows an initial assessment of

the risk of transmitting disease via produced foodstuff or through worker exposure (Westcot,

1997). Annex (3) shows the survival times of the pathogens in water are different from soil

and crops.

2.10 Chain of Infection

The potential for a biological agent to cause infection in a susceptible host depends on the

following factors:

2.10.1. Type of infectious agent:

Several infectious organisms may cause diseases in humans. These agents include bacteria,

fungi, protozoa, helminths, and viruses. The potential for causing illness depends on infectious

agents virulence and the stability of the infectious agent in the environment (soil, crops, and

water), and the minimal infective dose (MID). MID varies widely with the type of pathogen or

parasite (Bitton, 2005). As it illustrated in table (2.1) a few protozoan cysts or helminthes eggs

20

may be sufficient to establish infection; moreover, helminths are the most infectious agent

have a long persistence in environment.

Table 2.1: Epidemiological characteristics of enteric pathogens against their effectiveness

in causing infections through wastewater irrigation, source (Bitton, 2005).

Pathogen Persistence in

environment

Minimum

infective dose

Immunity Concurrent routes of

infection

Latency/soil

development

stage

Viruses Medium Low Long Mainly home contact,

food and water

No

Bacteria Short/medium Medium/high Short/medium Mainly home contact,

food and water

No

Protozoa Short Low/medium None/little Mainly home contact,

food and water

No

Helminthes Long Low None/little Mainly soil contact

outside home and food

Yes

In addition to the above factors minimal concurrent transmission through other routes such as

food, water, poor personal or domestic hygiene, and the need for a soil development stage

represent a main factors that contribute to the effective transmission of pathogens particularly

by wastewater irrigation. As shown in table (2.1) helminths (worms) diseases are the most

effectively transmitted by irrigation with raw wastewater because they persist in the

environment for relatively long periods; their minimum infective dose is small; there is little or

no immunity against them; concurrent infection in the home is often limited; they latency is

long, and a soil development stage is required for transmission. In contrast, the enteric viral

diseases should be least effectively transmitted by irrigation with raw wastewater, despite their

small minimum infective doses and ability to survive for long periods in the environment. Due

to poor hygiene in the home, and the prevalence of concurrent routes of infection in some

areas, most of the population has been exposed to and acquired immunity to the enteric viral

diseases as infants. Most enteric viral diseases impart immunity for life or at least for very

long periods, so that they are not likely to re-infect individuals exposed to them again, for

example, through wastewater irrigation, while the transmission of bacterial and protozoan

diseases through wastewater irrigation lies between these two extremes.

21

Shuval (1990) demonstrated that pathogens can be theoretically ranked in the following

descending order of risk:

1. High: Helminths infections,

2. Lower: Bacterial infections and Protozoan infections,

3. Least: Viral infections.

2.10.2. Reservoir of the infectious agent:

A reservoir is a living or nonliving source of the infectious agent allows the pathogen to

survive and multiply. The human body is the reservoir for numerous pathogens; person-to-

person contact is necessary for maintaining the disease cycle. Domestic and wild animals also

may serve as reservoirs for several diseases called zoonoses, that can be transmitted from

animals to humans. Nonliving reservoirs such as water, wastewater, food, or soils can also

harbor infectious agents (Bitton, 2005). Farmers are having more than one probably reservoir

for the infectious agents as they in direct contact with nonliving reservoirs elements in

addition to almost of them used to breed birds and animals in their farms which may serve as a

nonliving source of the infectious agent.

2.10.3. Mode of transmission:

Transmission involves transport an infectious agent from the reservoir to the host. As this is

the most important link in the chain of infection. Pathogens can be transmitted from the

reservoir to a susceptible host by various routes.

2.10.3.1. Person-to-Person transmission:

The most common route of transmission of infectious agents is from person to person.

2.10.3.2. Waterborne transmission:

Waterborne route is not, however, as important as the person-to-person contact route for the

transmission of fecally transmitted diseases. World Health Organization (WHO) reported that

diarrheal diseases contracted worldwide mainly by contaminated water or food, killed 3.1

million people, most of them children (WHO, 1996).

2.10.3.3. Foodborne transmission:

Food may serve as a vehicle for the transmission of numerous infectious diseases caused by

bacteria, viruses, protozoa, and helminthes parasites. WHO estimated that the accidental food

22

poisoning kills up to 1.5 million people per year. Food contamination results from unsanitary

practices during production or preparation. Vegetables contaminated with wastewater effluents

are also responsible for disease outbreaks (e.g., typhoid fever, salmonellosis, amebiasis,

ascariasis, viral hepatitis, and gastroenteritis). Raw vegetables and fruit become contaminated

as a result of being handled by an infected person during processing, storage, distribution or

final preparation, or following irrigation with fecally contaminated water (Bitton, 2005).

2.10.3.4. Airborne, Vector-Borne and Fomites transmission:

Some diseases can be spread by airborne transmission. This route is important in the

transmission of biological aerosols generated by wastewater treatment plants or spray

irrigation with wastewater effluents. The most common vectors for disease transmission by

vector- born are arthropods (e.g., fleas, insects) or vertebrates (e.g., rodents, dogs, and cats).

The pathogen may or may not multiply inside the arthropod vector. In addition to some

pathogens may be transmitted by nonliving objects or fomites (e.g., clothes, utensils, toys,

environmental surfaces) (Bitton, 2005).

2.10.4. Portal of entry

Pathogenic microorganisms can gain access to the host mainly through the gastrointestinal

tract (e.g., enteric viruses and bacteria), the respiratory tract, or the skin. Although the skin is a

formidable barrier against pathogens, wounds or abrasions may facilitate their penetration into

the host (Bitton, 2005).

2.10.5. Host Susceptibility

Both the immune system and nonspecific factors play a role in the resistance of the host to

infectious agents. Immunity to an infectious agent may be natural or acquired (Bitton, 2005).

Significant host immunity occurs only with the viral diseases and some bacterial diseases

(David; Mara & Sandy Cairncross, 1989) Its hypothesized that many farmers who use TWW

or the treatments plant workers acquired relatively high levels of permanent immunity to the

most of the common enteric viruses that endemic in their communities from their childhood

(Shuval, 1990).

23

2.11 Common Parasites Causing Waterborne Parasitic Diseases

2.11.1. Strongyloides stercoralis:

Strongyloides stercoralis is a nematode or a roundworm, in the genus Strongyloides. The

larvae are small; the longest reach about 1.5mm in length (CDC, 2017e).

2.11.1.1 S. stercoralis transmission:

S. stercoralis larvae found in contaminated soil and transmitted to the host when penetrate

their skin. Person-to-person transmission is rare but documented (CDC, 2016).

2.11.1.2. Strongyloidiasis symptoms:

For those who have the infection a local rash can occur immediately; the cough usually occurs several

days later; abdominal symptoms typically occur approximately 2 weeks later. Larvae can be found in

the stool about 3 to 4 weeks later. Most people infected with Strongyloides do not know they‘re

infected (CDC, 2017e). The infection may be severe and life-threatening in cases of immunodeficiency

(hematological diseases, immunosuppressive therapies), for this reason it is extremely important to

suspect, diagnose and treat the infection (WHO, 2017c).

2.11.1.3. S. stercoralis disease:

Strongyloidiasis is the disease that caused by the S. stercoralis. Most people do not know

when their exposure occurred. Where it is often associated with agricultural activities.

Therefore, activities that increase contact with the soil increase the risk of becoming infected,

such as: walking with bare feet, contact with human waste or sewage, and occupations that

increase contact with contaminated soil such as farming and coal mining (CDC, 2017e).

2.11.1.4. S. stercoralis diagnosis:

Strongyloidiasis is difficult to diagnose because the parasite load is low and the larval output

is irregular (Ericsson et al., 2001). Stool examination is currently the primary technique for the

detection of S. stercoralis infection. If the diagnosis is strongly suspected and special

techniques are not available, several specimens collected on different days should be

examined (Muennig et al., 1999).

24

2.11.1.5. Strongyloidiasis treatment:

Treatment of strongyloidiasis is recommended for all persons found to be infected, whether

symptomatic or not, due to the risk of developing hyper infection syndrome and/or

disseminated strongyloidiasis (CDC, 2017e). Ivermectin, thiabendazole and albendazole are

the most effective medicines for treating the S. stercoralis infection (WHO, 2017c).

2.11.1.6. Prevention and control of S. stercoralis:

The best way to prevent Strongyloides infection is to wear shoes through walking on soil and

avoiding contact with fecal matter or sewage. Proper sewage disposal and fecal management

are keys to prevention (CDC, 2017e).

2.11.1.7. S. stercoralis life cycle:

Figure (2.1): S. stercoralis life cycle

2.11.2 Ascaris lumbricoides:

A. lumbricoides is known as round worm. A. lumbricoides infection is one of the most

common intestinal worm infections (Hossain, 2009).

2.11.2.1. A. lumbricoides transmission:

It is found an association between poor personal hygiene, poor sanitation, and places where

human feces are used as fertilizer and Ascariasis. Ascariasis is caused by ingesting eggs. This

Eggs in feces

Eggs develop in

soil

adbnkabdj

Larvae penetrates

human skin

Larvae mature

in intestine

Adult worms in

intestine

Larvae

25

can happen when hands or fingers that have contaminated dirt on them are put in the mouth or

by consuming vegetables or fruits that have not been carefully cooked, washed or peeled

(CDC, 2017b).

2.11.2.2. Ascariasis symptoms:

Most people infected with A. lumbricoides have no symptoms. If symptoms do occur they can

be light and include abdominal discomfort. Heavy infections can cause intestinal blockage and

impair growth in children. Other symptoms such as cough are due to migration of the worms

through the body (CDC, 2017b).

2.11.2.3. A. lumbricoides disease:

Ascariasis is the diseas that cased by ingested Ascaris eggs.

2.11.2.4. A. lumbricoides diagnosis:

The diagnosis of ascariasis depends on the identification of the adult worms passed through

the rectum or from some other body orifice, or by identifying the eggs in the stool, vomitus,

sputum, or small bowel aspirate. Diagnosis during the stage of larval migration is difficult,

although occasionally larvae may be found in the sputum or gastric contents. Once the fertile

females within the gut begin to release eggs, the diagnosis of ascariasis can usually be made

by direct fecal smears. However, concentration techniques using centrifugation (e.g., formalin-

ethyl acetate method) may facilitate diagnosis (Hossain, 2009).

2.11.2.5. Ascariasis treatment:

Roundworm is usually treated with antiparasitic drugs. Medications most commonly used for

treatment include: albendazole (Albenza), ivermectin (Stromectol), or mebendazole. In

advanced cases, other treatment may be needed. Surgery may be used to control a larger

infestation (Health line, 2017)

2.11.2.6. Prevention and control of A. lumbricoides:

The best defense against ascariasis is practicing good hygiene before handling food by

washing the hands with soap and water and washing fresh fruits and vegetables thoroughly

(Mayo Clinic, 2017).

26

2.11.2.7. A. lumbricoides life cycle:

Figure (2.2): A. lumbricoides life cycle

2.11.3. Cryptosporidium sp.

Cryptosporidium is a microscopic parasite protected by an outer shell that allows it to survive

outside the body for long periods of time and makes it very tolerant to chlorine disinfection

(CDC, 2017c).

2.11.3.1 Cryptosporidium transmission:

Cryptosporidium can be transmitted directly via person to person, animal to human, animal to

animal, or indirectly by water, food and possibly via air (Fayer et al., 2000). Animals were

considered to be a reservoir of Cryptosporidium (Cama et al., 2003; Learmonth et al., 2004).

Children infected with Cryptosporidium hominis shed higher levels of oocysts because they

have underdeveloped immune system and oocysts can proliferate easier (Xiao et al., 2001).

2.11.3.2. Cryptosporidiosis symptoms:

Symptoms of cryptosporidiosis generally begin 2 to 10 days after becoming infected with the

parasite which are watery diarrhea, stomach cramps or pain, dehydration, nausea, vomiting,

fever, and weight loss. Some people with Crypto will have no symptoms at all. Symptoms

usually last about 1 to 2 weeks in persons with healthy immune systems. While the small

intestine is the site most commonly affected, in immunocompromised

persons Cryptosporidium infections could possibly affect other areas of the digestive tract or

Migrate to lungs from where are

coughed up or swallowed again

Final development in

small bowel

Unfertilized egg

Fertilized egg

Infective larvae

Egg in soil

Reach duodenum, penetrate its

wall and go to blood

Ingested with food

27

the respiratory tract. The risk of developing severe disease may differ depending on each

person's degree of immune suppression (CDC, 2017c).

2.11.3.3 Cryptosporidiosis:

Cryptosporidium causes the diarrheal disease cryptosporidiosis. Both the parasite and the

disease are commonly known as "Crypto." Cryptosporidium parvum and Cryptosporidium

hominis are the most prevalent species causing disease in humans (CDC, 2017c).

2.11.3.4. Cryptosporidium diagnosis:

Diagnosis of cryptosporidiosis is made by examination of stool samples. Most often, stool

specimens are examined microscopically using different staining techniques, the staining

methods of most commonly used are the modified Ziehl-Neelson acid-fast stain and modified

Kinyoun's acid-fast stain (Zaglool et al., 2013). Molecular methods can be used to

identify Cryptosporidium at the species level (CDC, 2017c).

2.11.3.5. Cryptosporidiosis treatment:

Most people who have healthy immune systems will recover without treatment. Diarrhea can

be managed by drinking plenty of fluids to prevent dehydration (CDC, 2017c). Nitazoxanide

is approved to treat cryptosporidiosis in immunocompetent people aged ≥1 year (CDC, 2016)

2.11.3.6. Prevention and control of Cryptosporidiosis:

To control cryptosporidiosis: a) Practicing good hygiene, b) avoiding water that might be

contaminated, and c) avoiding touching farm animals are recommended (CDC, 2017c).

2.11.3.7. Cryptosporidium life cycle:

The oocysts become infective

(sporulate) in the external

environment

The host is infected when it

ingests oocysts in water or food

contaminated with fecal material

Oocyst excysts in the

small intestine

Oocysts are

passed in the

host‘s feces

Sexual and asexual

reproduction and oocysts

are produced

Figure (2.3): Cryptosporidium life cycle

28

2.11.4. Entamoeba histolytica:

Although several protozoan species in the genus Entamoeba colonize humans, not all of them

are associated with disease. E. histolytica is well recognized as a pathogenic amoeba causing

amebiasis. The other Entamoeba species are important because they may be confused with E.

histolytica in diagnostic investigations (Pritt & Clark, 2008).

2.11.4.1. E. histolytica transmission

Transmission occurs via the fecal–oral route, either directly by person-to-person contact or

indirectly by eating or drinking fecally contaminated food or water (WHO, 2017a).

2.11.3.2. E. histolytica disease:

Amebiasis is the disease that caused by E. histolytica.

2.11.4.3. Amebiasis symptoms:

Only about 10% to 20% of people who are infected with E. histolytica become sick from the

infection. The symptoms are often quite mild and can include loose feces, stomach pain, and

stomach cramping. Amebic dysentery is a severe form of amebiasis associated with stomach

pain, bloody stools, and fever. Rarely, E. histolytica invades the liver and forms an abscess (a

collection of pus). In a small number of instances, it has been shown to spread to other parts of

the body, such as the lungs or brain, but this is very uncommon (CDC, 2017a).

2.11.4.4. Amebiasis treatment:

For symptomatic intestinal infection and extraintestinal disease, treatment with metronidazole

or tinidazole should be followed by treatment with iodoquinol or paromomycin.

Asymptomatic patients infected with E. histolytica should also can be treated with iodoquinol

or paromomycin, because they can infect others and because 4%–10% develop disease within

a year if left untreated (CDC, 2016).

2.11.4.5. E. histolytica diagnoses:

Microscopy does not distinguish between E. histolytica (known to be

pathogenic), E. bangladeshi, E. dispar, and E. moshkovskii.

E. dispar and E. moshkovskii have historically been considered non-pathogenic. More specific

tests such as Enzyme immunoassay techniques or Polymerase chain reaction are needed to

29

confirm the diagnosis of E. histolytica. Additionally, serologic tests can help diagnose extra-

intestinal amebiasis (CDC, 2016).

2.11.4.6. Prevention and control of E. histolytica:

Good sanitary practice, as well as responsible sewage disposal or treatment are necessary for

the prevention of E. histolytica infection on an endemic level. E.histolytica cysts are usually

resistant to chlorination, therefore sedimentation and filtration of water supplies are necessary

to reduce the incidence of infection (Madigan et al., 2010).

2.11.4.7. E. histolytica Life cycle:

Figure (2.4): E. histolytica Life cycle

2.11.5. Giardia lamblia:

G. lamblia is a parasite protected by an outer shell that allows it to survive outside the body

for long periods of time and makes it tolerant to chlorine disinfection (CDC, 2017d).

2.11.5.1. G. lamblia transmission:

G. lamblia is found on surfaces or in soil, food, or water that has been contaminated with

feces from infected humans or animals. While the parasite can be spread in different ways,

water (drinking water and recreational water) is the most common mode of transmission

(CDC, 2017d). Infection usually occurs through ingestion of G. lamblia cysts in water

(including both unfiltered drinking-water and recreational waters) or food contaminated by the

feces of infected humans or animals (WHO, 2017b).

Resistant, infective cysts /

Trophozoites passed in feces

Human ingests infective

cysts/trophozoites;

transmitted by feces,

fingers, food, fomites,

and flies

Cyst passes to small

intestine; excystation

occurs

Trophozoites multiply

and produce cysts

30

2.11.5.2. G. lamblia symptoms:

Symptoms of giardiasis may last 2 to 6 weeks. Occasionally, symptoms last longer (CDC,

2017d). Symptoms include abdominal pain, foul smelling diarrhea, foul smelling gas, and

mechanical irritation of intestinal mucosa with shortening of villi and inflammatory foci.

Malabsorption syndrome may occur in heavy infection (Leventhal & Cheadle, 2002).

2.11.5.3. G. lamblia disease:

Giardiasis is the disease that caused by G. lamblia.

2.11.5.4. Giardiasis treatment:

Several drugs can be used to treat Giardiasis. Effective treatments include metronidazole,

tinidazole, and nitazoxanide (Letter, 2010) Alternatives to these medications include

paromomycin, quinacrine, and furazolidone (Escobedo & Cimerman, 2007; Letter, 2010).

Different factors may shape how effective a drug regimen will be, including medical history,

nutritional status, and condition of the immune system (Solaymani-Mohammadi, et al., 2010;

Upcroft & Upcroft, 1993).

2.11.5.5.Prevention and control of G. lamblia disease:

There is no vaccine to prevent Giardiasis in humans, nor any recommended

chemoprophylaxis, a good hygiene practice, as well as consuming clean water are necessary

to reduce the incidence of infection (Giardiaclub, 2017).

2.11.5.6. G. lamblia life cycle:

cysts passed in feces

Human ingests infective cysts;

transmitted by feces, fingers, food,

fomites, and flies and infected water

Cyst passes to small

intestine; excystation

occurs

Trophozoites in small;

intestine multiply

asexually by binary

fission

life cycle G. lambliaFigure (2.5):

31

2.11.6. Microsporidia

Microsporidia are eukaryotic parasites that must live within other host cells in which they can

produce infective spores. Although there are over 1,200 species of microsporidia, there are 15

species that have been identified as causing disease in humans (Doerr, 2017).

2.11.6.1. Microsporidia symptoms:

Chronic diarrhea and wasting are the most common symptoms of microsporidiosis, the

different Microsporidia species invade different sites including the cornea and muscles. Thus,

the symptoms of microsporidiosis varies greatly depending on the site of infection (Smith,

2017).

2.11.6.2. Microsporidia disease:

Microsporidiosis is a disease caused by infection with Microsporidia. Microsporidiosis is

primarily seen in individuals infected with human immunodeficiency virus (HIV), although it

can rarely also cause disease in individuals with a normal immune system. Microsporidiosis

can cause infection of the intestine, lung, kidney, brain, sinuses, muscles, and eyes (Doerr,

2017).

2.11.6.3. Microsporidia diagnosis:

Infecting organisms can be demonstrated in specimens of affected tissue obtained by biopsy or

in stool, urine, Cerebrospinal fluid , sputum, or corneal scrapings. Microsporidia are best seen

with special staining techniques as the modified Ziehl-Neelson acid-fast stain. Fluorescence

brighteners (fluorochromes) are used to detect spores in tissues and smears. The quick-hot

Gram chromotrope technique is the fastest. Immunoassay and PCR-based assays hold promise

for the future. Transmission electron microscopy is currently the most sensitive test and is

used for speciation (Pearson, 2017).

2.11.6.4. Microsporidia Treatment:

The treatment of microsporidiosis is generally achieved with medications and supportive care.

Depending on the site of infection and the microsporidia species involved, different

medications are utilized. The most commonly used medications for microsporidiosis

include albendazole (Albenza) and fumagillin (Doerr, 2017).

32

2.11.6.5. Microsporidia life cycle:

Figure (2.6): Microsporidia life cycle

2.12 Health Protection Measure for Reduction Health Risks Associated with

TWWR in Agriculture

The groups potentially most at risk from wastewater reuse in agriculture are the farm workers,

their families, crop handlers, consumers of crops, and those living near wastewater-irrigated

areas. The approach required to minimize exposure depends on the target group. Farm workers

and their families have higher potential risks of parasitic infections (Blumenthal et al., 2000).

2.12.1. Reducing health risks associated with wastewater irrigation approaches

2.12.1.2.Wastewater treatment:

When wastewater is treated with the intention of using the effluent for agricultural irrigation

and not disposal in receiving water, the important quality criteria are those relevant to human

health rather than environmental criteria should be considered. Therefore, fecal coliform

removal and nematode egg removal are more important than BOD removal (Blumenthal, et

al., 2000).

2.12.1.3.Wastewater application and human exposure control:

Irrigation water including treated wastewater can be applied to the land in the five following

general ways (WHO, 1989):

The oocytes become infective

(sporulate) in the external

environment

The host is infected when it

ingests oocytes in water or food

contaminated with fecal

material

Oocyte ex-cysts in the

small intestine

The spore

extrudes its polar

tubule and infects

the host cell

sexual and asexual

reproduction and oocytes

are produced

33

1. Flooding (border irrigation): almost all the land surface is wetted;

2. By means of furrows: only parts of the ground surface is wetted;

3. By means of sprinklers: the soil and crops are wetted in much the same way as they are

by rainfall;

4. By subsurface irrigation: the surface is only slightly wetted, if at all, but the subsoil is

saturated,

5. By means of localized (trickle, drip, or bubbler) irrigation: water is applied to the root

zone of each individual plant at adjustable rate.

Choosing a wastewater application method can impact on health protection of farm workers,

consumers, and nearby communities. For example using sprinklers have the highest potential

to spread contamination on crop surfaces and affect nearby communities. Farm workers and

their families are at the highest risk when furrow or flood irrigation techniques are used. This

is especially true when protective clothing is not worn and earth is moved by hand. Protection

can be achieved by low-contaminating irrigation techniques (as subsurface and localized),

together with wearing protective clothing (e.g. footwear for farmers and gloves for crop

handlers) and improving levels of hygiene both occupationally and in the home can help to

control human exposure. localized irrigation (drip, trickle and bubbler irrigation) can give the

greatest degree of health protection by reducing the exposure of workers to the wastewater

(Blumenthal, et al., 2000).

2.12.1.4. Crop restriction

Crop restriction can be used to protect the health of consumers. For example water of poorer

quality can be used to irrigate non-vegetable crops such as cotton or crops that will be cooked

before consumption (e.g., potatoes). However, crop restriction does not provide protection to

the farm workers and their families where a low quality effluent is used in irrigation or where

wastewater is used indirectly (i.e., through contaminated surface water) (Blumenthal, et al.,

2000).

2.12.1.5. Pathogen die-off before consumption:

The interval between final irrigation and consumption reduces pathogens (bacteria, protozoa

and viruses) populations by approximately 1 log unit per day (Petterson & Ashbolt, 2003).

The precise value depends upon climatic conditions, with more rapid pathogen die-off

34

(approximately 2 log units per day) in hot, dry weather and less (approximately 0.5 log unit

per day) in cool or wet weather without much direct sunlight (Amoah, 2008). A period of

cessation of irrigation before harvest (1-2 weeks) can allow die-off of bacteria and viruses

such that the quality of irrigated crops improves to levels seen in crops irrigated with fresh

water (Vaz da Costa Vargas et al., 1996). However it must be stressed that helminth eggs can

remain viable on crop surfaces for up to two months, although few survive beyond

approximately 30 days (Strauss, 1996).

2.12.1.6. Chemotherapy and vaccination

Chemotherapy and immunization cannot normally be considered as an adequate strategy to

protect farm workers and their families exposed to raw wastewater or excreta. Immunization

against helminthic infections and most diarrhoeal diseases is currently not feasible.

Chemotherapeutic control of intense nematode infections in children and control of anemia in

both children and adults, especially women and post-menarche girls is important.

Chemotherapy must be reapplied at regular intervals to be effective – as many as 2–3 times a

year for children living in endemic areas (Montresor et al., 2002)

2.13 Treated Wastewater Reuse Guidelines

Wastewater reuse guidelines are put to protect the population from health risk and the

environment from degradation and pollution. Most of the worldwide available guidelines are

based on either the US EPA guidelines (US EPA, 2004) or the WHO guidelines (WHO, 1989).

These guidelines are suitable for developed countries with anyway high wastewater treatment

standards, but should be adjusted in developing countries and account for the end use

(Choukr-Allah, 2010).

The guideline should include assessment of the irrigation method, exposure scenario and

hygiene measures (Blumenthal & Peasey, 2002). The revised 1989 WHO guidelines and

recommended guidelines for water reuse in the Mediterranean region in addition to Palestinian

wastewater reuse standard are shown in Annex (4).

35

Chapter III

Methodology

This chapter presents all issues related to methodology that used to answer the study

objectives, which are study design, population, setting, period, eligibility criteria, instruments,

ethical and administrative consideration, sampling size and process, questionnaire

formulation, piloting, laboratory procedures, data entry and analysis, and study limitation.

3.1 Study Design

The present study is a comparative study aimed to investigate the parasitic infection among

farmers dealing with treated wastewater in Al-Zaitoun area, Gaza City. In order to understand

the risk of dealing with TWW in agriculture; the parasitic infection between farmers who

irrigate by groundwater was investigated as a benchmark '' for comparison''. The design of

comparative research is simple; study objects are specimens or cases which are similar in

some respects (otherwise, it would not be meaningful to compare them) but they differ in

some respects. These differences become the focus of examination. The goal is to find out

why the cases are different to reveal the general underlying structure which generates or

allows such a variation (Routio, 2017).

3.2 Study Population

The present study included two farmer groups: farmers who dealing with TWW in agriculture

through the summer season (Mixed water users (MWUs) Exposed group) and farmers who

irrigate by using GW (agricultural/private/municipal wells) (Ground water users (GWUs)

Non-exposed group).

3.3 Study Setting

3.3.1. Study areas

The present study carried out in Gaza strip at two different agricultural areas: The first

agricultural area was approximately around 100 dunams at Al- Zaitoun area next to Gaza car

shop (west of Salah El-Deen street) and away of 800 m from Gaza treatment plant.

36

In this agricultural area a pilot project called Sheikh Ejleen Pilot Project was initiated in 2004

when JCP in cooperation with PHG had proposed a project to use the TWW from GWWTP

for irrigating 100 dunams of citrus and olive trees. This pilot project was funded from French

program called ―Strategy of agricultural water management in the Middle East", supervised

from PWA and Municipality of Gaza with coordination with MOH and MOA. It aimed to

demonstrate the interest of using TWW for the irrigation of citrus and olive orchards. This

project was successful, thereafter, extension has made till the last Israeli invasion that led to

the destruction of some of infrastructure of the project. However, rehabilitation was done

under the French and Spanish funds to be operate again on November 2010 covering 186

dunum (Austrian Development Cooperation & Palestinian Water Authority, 2011). Finally this

project temporarily was stopped as a result of the maintenance works in GWWTP from 2013

to 25.July 2016; the location of pilot project is shown in Annex (5). From 2010 to 2013 it is

decided to install two parallel post wastewater treatment systems: sand filter and reed bed. The

effluent of the pilot post-treatment plant was used for the growth of citrus and olives. This

would require Class B water quality (BOD=20 mg/l, TSS=30mg/l, and Fecal coliform=1000

MPN per 100 ml), according to the Guidelines for wastewater reuse for irrigation in Palestine.

The total capacity of the pilot post treatment system is 1,000 m3/d. This equals 62.5 m3/h.

50% of this flow to be treated in a sand filter and the remainder to be treated in a reed bed

system. The treated effluent from both sand filter and reed bed is stored in a 600 m3 reservoir

prior to be used as irrigation water (Austrian Development Cooperation and Palestinian

National Authority, 2013), the post wastewater treatment system layout is shown in Annex (6).

The second agricultural area was approximately around 40 dunams at Joher Al-Deek area

(east of Salah El-Deen street). This area was chosen to be as a control area based on the

following conditions: a) Far away from the exposed area or the agricultural lands that irrigated

by TWW, b) Irrigated by groundwater only.

3.3.2 Study period

The present study carried on two stages: the proposal writing with time period from

September, 2015 till January, 2016 and the practical and experimental part which consumed

period of one year from study proposal approval in February, 2016 till February, 2017, since

the maintenance works in GWWTP delayed the TWW pumping process for exposed group for

37

three months about the expected date on 01 April, 2016. According the actual TWW pumping

for farmers was on 28 July,2016. The practical and experimental part was conducted on two

phases: the first phase was in May and beginning of June 2016 in which each farmer groups

were using the GW in irrigation. The second phase was in November and December 2016

after the exposed farmers' group used the TWW in irrigation for period of three months from

28.08.2016 – 27.11.2016.

3.4 Study Eligibility Criteria

3.4.1. Inclusion criteria:

The inclusion criteria for the exposed group were as follows:

1. Farmers who are dealing with TWW for at least two years

2. Farmers who are use the TWW in agriculture under PWA or any other association

supervision.

3. Farmers will accept to provide researcher with stool samples, and will be ready to fill

the questionnaire.

The Inclusion Criteria for the non-exposed group were as follows:

1. Farmers who irrigate by groundwater only and don‘t use previously TWW in their

agricultural lands.

2. Farmers who live far away from the TWW fed agriculture lands

3. Farmers will accept to provide researcher with stool samples, and will be ready to fill

the questionnaire.

3.4.2. Exclusion criteria

Any farmer hasn't the above inclusion criteria was excluded from study.

3.5 Study Instruments

Stool, Irrigation water, soil, and farmers hand washing water samples in addition to filling an

interview structured questionnaire were used to fulfill study objectives.

38

3.5.1. Stool samples, Irrigation water, soil, and farmers hand washing water samples:

Each farmer was asked to provide stool samples in addition soil, irrigation water, and hand

washing water samples were collected from each farmer at the two study phases. Stool

samples in 1st phase aimed to ensure that all farmers are non-parasitic infected before the 2

nd

phase ''in which the MWUs will use TWW in irrigation for three months in order to

investigate its effect on parasitic infection''; otherwise, he/she will be excluded from the

sample or treated before beginning the second phase.

Soil, irrigation water, and the hand washing water samples were asked in order to establish

baseline data about parasitic load in the environmental mediums at each farmer.

The second phase was to compare the difference in parasitic infection prevalence between

exposed farmers who irrigated their lands with TWW for three months and non-exposed

farmers who still using GW and to compare the parasitic load in soil and irrigation water at

each farmer according to the baseline data.

3.5.2. An interview structured questionnaire:

Interview structured questionnaire with eight sections was developed in February, 2016. The

questionnaire was taken the final version as shown in Annex (7) by March 2016 after most of

validation committee (Annex (8)) which was composed from 12 specialists comments were

taken in consideration and pilot study was carried out. The questionnaire was used in a face-

to-face interview conducted by researcher and assistant. The researcher accompanied the

assistant in each time to supervised him/her and to make sure that the procedure was precisely

followed. Each interview was taken approximately 20 minutes.

Questionnaire was administered to all cases and controls with the following sections: (a)

General demographic and socio-economic information about farmer: Name, phone number,

address, age, gender, educational level, family size, occupation, and economic and financial

status, (b) Housing characteristics: home building materials, its land type, and type of the area

that around it, (c) General information about participant agricultural activities: Farm address,

area, daily spent time in the farm, cultivated pants, (d) Home water conditions; general water

conditions was assessed by following indicators: Source of drinking water, type of non-

drinking water used in the home, and total consumed non-drinking water, (e) Home sanitary

conditions; general sanitary conditions was assessed by following indicators: Home sanitation

39

disposal method, farm toilet, and its sanitation disposal method, (f) Bird and animal breeding;

general bird and animal breeding was assessed by following indicators: Place of breeding the

birds and animals, and types of the breeding birds and animals, (g) Farmer's hygiene behavior;

hygiene behavior status was assessed by three models: Personal hygiene inside home, through

harvesting process, and through working in the farm as (location of the home cooking place,

soap consumption, wearing protection tools during field work (gloves, boots, etc.), hand

washing, and eating habits), and (h) Farmer's health status: General health status was assessed

by asking about the gastrointestinal symptoms as: Vomiting, abdominal pain, blood/mucus

stools, etc.

3.5.2.1 Pilot study:

Before starting the actual data collection process, a pilot study was carried out with 6 farmers

to examine farmers response to questionnaire questions, to identify how they will understand

it, and to measure validity and reliability. Another studies revealed that the pilot study used to

examine the clarity and ambiguity, length and suitability of questions before the data

collection process starts (Polit & Beck, 2004). Moreover studies reveled the pilot phase is also

practical for detecting major defects in questionnaire design. Pilot work can be costly but it

will avoid a great deal of wasted effort on unintelligible questions producing unquantifiable

responses and uninterruptable results (Oppenheim, 2000). After the pilot study slight

amendments on questionnaire were done.

3.5.2.2 Reliability:

To ensure study reliability the following steps were done:

1. Standards methods were used for samples analysis as illustrated in section 3.9.

2. Each sample analyzed duplicated or/and many sequences analysis methods were used

for more precise result.

3. When researcher seeked assistance, she was accompany the assistant to guide him and

to ensure he did the work as required.

4. Data entry were done in the same day of data collection to allow any required possible

corrections.

5. All data was re-entered after finishing data entry process to ensure correct entry

procedure and decrease entry errors.

40

3.6 Ethical and Administrative Considerations

An approval from public health school at Al Quds University and ethical approval from

Helsinki Committee were obtained; the ethical approval is shown in Annex (9). In addition to

researcher asked an approval from Director of Preventive Medicine in MOH for purpose of

providing suitable treatment for the infected farmers. To guarantee/protect participants rights,

a consent form indicating that the participation is voluntary and confidentiality assured for all

participants before interviews and samples collection, as shown in Annex (10).

3.7 Samples Size and Process

3.7.1. Farmers participants:

Two awareness/orientation sessions were conducted in May, 2016 for exposed and non-

exposed farmers' group respectively to increase farmers awareness, knowledge about parasitic

infection that result from working in agriculture and in the same time to obtain their consent

for participation in the study. Most of farmers had agreed to participate, cooperate and commit

in the study requirements (providing stool, soil, irrigation water, and hand washing water

samples at the two phases in addition to filling questionnaire). The number of exposed group

was 36 participants, while the number of non-exposed group was 19 participants (2:1).

Sampling approaches (Probability and Non-probability) were not used in this study because

researcher used all accessible population in the two study areas.

3.7.2. Stool samples:

Each farmer was asked to provide three consequently stool samples on separate days to be

submitted with no more than 10 days at the two phases. Three stool samples are considered a

minimum for an adequate parasitic detection since many organisms particularly the intestinal

protozoa do not appear in stool in consistent numbers on a daily basis (Garcia & Bruckner,

2001). In addition to educational materials about collecting representative stool sample, three

stool cups with 4ml of 10% formalin as a preservative, and three paper bags were distributed

to each participant to provide preserved samples.

41

3.7.3. Treatment of the infected farmers in the first phase:

After the 1st phase and the 2

nd phase each farmer had infection, he/she treated by proper

chemotherapy with coordination with in Rimal healthcare center and under supervision a

physician at Al-Zaitoun Healthcare center, Annex (11) shows samples from the medical

prescription documents.

Table 3.1 : Medication types that used for treated infected farmers

Parasite Medication Frequency

Entamoeba histolytica/dispar cyst Cystogen 2*3*10 (adults)

5cc *3*10 (children)

Giardia lamblia cyst Cystogen 2*3*10 (adults)

5cc *3*10 (children)

Cryptosporidium sp. (Oocyst) Azicare 5 tables (500mg) per day

(adults)

5cc per day (children)

Microsporidium sp. (Oocyst) Albendazole 1*2*14 (adults and children)

Ascaris lumbricoides Vermox 5cc *2*3 (children)

Strongyloides stercoralis Albendazole 0.5*2*14 (children)

3.7.4. Soil samples:

Soil composite samples from each farm of participant were taken randomly (2-3 samples per

each donum) by using a soil auger and sterile spatulas from the top of 0 – 20 cm layer that

around trees in the two phases. Where crops and farmers are more susceptible for

microorganisms in this depth.

3.7.5. Irrigation water samples:

Sampling of irrigation water was carried out between 07:30 and 12:00 AM and between 05:30

and 07:30 PM when farmers were irrigating. Two liter of irrigation water were collected

directly from irrigation water pipes by using 4 L plastic container from each farmer ''to be

sufficient to contain the sample and the preservative solution''. The irrigation water source in

the first phase was GW for the two farmer' groups, but in the second phase it was TWW

regarding the exposed group only.

Through the second phase monthly wastewater samples from GWWTP inlet, outlet and from

the wastewater treatment systems reservoir were taken to monitor wastewater quality.

42

3.7.6. Farmers Hand washing water samples

Each farmer was asked to give hand washing water. Distilled water (1 L for each farmer) was

used to wash farmers hands, and 1.5 L plastic container was used for collecting their hands

washing water.

3.8 Laboratory Procedure

All collected samples were sent to Islamic University Lab, for preservation and parasitic

analysis.

3.8.1 Equipment sterilization:

Samples collection equipment were washed with soap, rinsed with distilled water, disinfected

with 70% ethanol, and then put to air-dried. Working benches and all equipment that used in

the analysis were cleaned and disinfected with 70% ethanol before and after use to avoid

microbial contamination and to sterilize the materials used for analysis and prevent cross

contamination.

3.8.2 Samples labeling:

Each sample was labeled; date, time of collection in addition to any special notes were written

through samples collection.

3.8.3 Samples preservation:

All samples were preserved through collection process to facilitate collection and to keep the

morphology of the parasites stages. As reported in standard methods for the examination of

water and wastewater book; nematode mortality and deterioration of diagnostic characteristics

begins at time of collection, so process samples for diagnosis should be within 24 hr. and

completing the full diagnostic processing should be within 48 hr. (APHA, 2005). Samples

preservation were depended in this study, as there is a lag time from samples collection time

and the examination process in laboratory since the number of samples are high, researcher

can't do all required analysis in short period, in addition to the researcher is restricted in

assigned working hours in the laboratory.

43

The following preservation methods were followed to preserve the different samples:

3.8.3.1 Stool samples preservation:

The collected stool samples preserved by using 10% formalin to keep protozoan morphology

and to prevent the continued development of some helminth eggs and larvae. According to

studies formalin has been used for many years as an all-purposes fixative that is appropriate

for helminth eggs, larvae and protozoan cysts, oocysts, and spores (Garcia & Bruckner, 2001).

3.8.3.2 Irrigation water and hand washing water samples preservation:

Liquid samples were preserved by adding equal volume of 8% formalin solution to sample. As

the cold storage retards, but does not entirely halt deterioration and rot (APHA, 2005).

3.8.3.3 Soil samples preservation:

Soil samples were preserved by using ''hot preservative'' as follows:

1. About 100 ml (40 %) formalin + 10 ml Glycerine + 890 ml distilled water were added

in thermal beaker at about 80oC

2. Then hot preservative was added to the all collected soil sample ''each sample was

around one kilogram''.

3. Soil and hot preservative was shaken in order to hot preservative fully penetrates

through all soil sample.

4. Finally, soil samples were stored at room temperature (21oC).

A study revealed that the numbers of nematodes were recovered from the fixed samples by hot

preservative were significantly greater than those recovered from non-fixed samples for six

studied nematodes species out of seven nematodes species (Elmiligy & Grisse, 1970).

3.9 Detecting of parasites stages in stool, irrigation water, hand washing

water, and soil samples

3.9.1 Detecting of parasites in stool samples:

In this study, the microscopic examination of the stool samples consists of three separate

techniques: direct wet smear, concentration (sedimentation), and permanent stained smear.

44

3.9.1.1 Direct Wet Mount method:

Principle:

Direct wet smear is a rapid screening technique (Leventhal & Cheadle, 2002).

Procedure:

Direct wet mount was applied according to (Garcia & Bruckner, 2001) as follows:

1. One drop of saline NaCl (0.85%) was placed on slide by using dropper,

2. A small amount of stool sample picked up by using a wooden applicator stick,

3. Stool drop was put on slide and thoroughly emulsified in the saline,

4. Slide (suspension) was covered by 22 mm coverslip (no. 1),

5. Suspension systematically was scanned with 10X objective and 40X objective.

3.9.1.2. Concentration (Sedimentation) method:

Principal:

All parasites were detected on a direct mount of preserved stool, it certainly be seen through

the concentration examination, in addition to concentration technique allows detection the

small numbers of organisms that may be missed by using direct wet smear. There are two

types of concentration procedures, sedimentation and flotation, both of them are designed to

separate protozoan organisms and helminth eggs and larvae from fecal debris by

centrifugation and/or differences in specific gravity, but the sedimentation procedure is

recommended as being the easiest to perform and the least subject to technical error (Garcia &

Bruckner, 2001).

Procedure:

As the stool samples were preserved in 10% formalin, the procedure was applied according to

(Garcia & Bruckner, 2001) for preservative samples as follows:

1. Stool preservative mixture was stirred,

2. A sufficient quantity 3-4 ml of the stool formalin mixture was strained through small

screen in a conical centrifuge tube to give the desired amount of sediment (0.5 to 1 ml),

3. About 10% formalin was added to the top of the tube, centrifuged for 10 min at ( 500

Xg). The amount of sediment obtained should be approximately 0.5 – 1 ml.

45

4. The supernatant fluid was discarded and the sediment on the bottom of the tube was

suspended in (7ml) 10 % formalin (fill the tube half full only), then 4 to 5 ml of ethyl

ether was added, tubes were stoppered and shacked vigorously for at least 30s. and

holded so that the stopper is directed away from face.

5. After a 15 – 30s waiting, tubes centrifuged for 10 min. at 500 Xg, as a result four

layers were resulted: a small amount of sediment (containing the parasites) in the

bottom of the tube, a layer of formalin, a plug of fecal debris on top of the formalin

layer, and a layer of ethyl ether at the top.

6. All supernatant fluid was decanted and discarded.

7. From 1 to 2 drops of formalin were added to the sediment, then tubes kept for

microscopic reading.

8. Small amount of sediment was added to a slide, then coverslip (22mm by 22mm, No.

1) was added and slide was examined under microscope with 10X objective and 40X

objective.

3.9.1.3. Permanent stained smear (Modified Ziehl-Neelsen Technique (Acid-fast stain)):

Principal:

Permanent stained smear (Acid-fast staining) was used for detection and identification of

small protozoan organisms that missed with the direct smear and concentration methods as

Cryptosporidium and Microsporidia.

Procedure:

Acid-fast stain was applied according to (WHO, 1994) as follows:

1. A thin smear of feces was prepared on frosted slide by using a wooden applicator,

2. Smear was left in air till be dried,

3. After smear became dried, slides was fixed in absolute methanol for 2-3 min,

4. Then, slides were stained with hot carbol-fuchsin for 5-10 min, then differentiate in 1%

HCl-ethanol until color ceases to flow out of smear; after that slides were rinsed in tap

water, (for preparation 1 liter of 1% HCL; 990ml (70% ethanol) was added to 10ml

concentrated HCL.

5. Slides were counterstained with 0.25% methylene blue for 30 sec., then rinsed in tap

water,

46

6. Finally slides were blotted or drained dry and became ready for microscopic using an

oil objective (100X).

3.9.2. Detecting of parasites in irrigation water/Hand washing water and Soil samples:

Detecting helminth eggs and protozoa in irrigation water, hand washing water (Liquid

samples), and soil samples conducted by using method was adapted from Reimer et al (1981)

(as cited in (Yanko, 1988)) and the Modified EPA method (Schwartzbrod, 1998).

Principal:

Many methods for detection and identification helminths and protozoa in environment

mediums were revised. The method that performed in this study for the only method it found

suitable for detection helminths and protozoa in the same time (simultaneously), as the other

methods were for detection a specific helminths or protozoa species. In addition to all other

methods used a number of different chemicals for flotation the parasites, while the performed

methods in this study used Zinc Sulfate Heptahydrate with specific gravity of 1.2. Studies

revealed that for many years there is a certain substances were more efficient in floating

protozoan cysts while others were more satisfactory in recovering helminth eggs (Farr &

Luttermoser, 1941), it was found by Faust et al (1938,1939) (as cited in (Farr & Luttermoser,

1941)) zinc sulfate with specific gravity of 1.18 is the flotation solation that can recover the

largest number of protozoan cysts and helminths eggs.

Procedure:

Test for protozoan:

1. For liquid (Irrigation water (GW/TWW)/ hand washing water samples); homogeneous

samples of 2 liter volume was put in 3 liter beaker; while for solid samples (soil

samples) 30 gram dry weight of soil was put in 1 liter beaker,

2. Then 100 ml sterile phosphate buffer solution containing 0.1 '' concentrated tween 20''

were added for the prepared beakers,

3. Homogenized sample of 100 ml volume was measured into two 50 ml centrifuge tubes

and centrifuged at 1250 RPM for 6 min,

4. Supernatant was poured off and pellet re-suspended in Zinc Sulfate Heptahydrate (1.2),

5. Tubes (sample plus Zinc Sulfate Heptahydrate (1.2)) were centrifuged at 1250 RPM

for 6 min,

47

6. Surface of the Zinc Sulfate Heptahydrate was carefully aspirated and transferred to a

50 ml conical centrifuge tube,

7. Deionized water (10ml) was added to the Zinc Sulfate Heptahydrate and centrifuged at

1400 RPM for 6 min,

8. Supernatant was poured off and pellet re-suspended in (7ml) acid-alcohol solution (0.1

N sulfuric acid in 35% ethanol) solution, for preparing 1 liter acid-alcohol solution;

350 ml absolute ethanol was added to 5.16 ml ethanol H2SO4 and then solution

completed to 1 liter by using distilled water.

9. Approximately 3 ml of ether was added,

10. The tube was centrifuged at 1800 RPM for 6 min, then acid – alcohol, ether (350 ml

ethanol and 5.16 ml H2SO4, add sufficient distilled water to produce 1L of the

solution) and plug was poured off and the tube inverted over a paper towel to prevent

reagent from running back into tube.

11. After well drained, two drops of formalin were added to the pellet and mixed to

preserve the sample waiting the microscopic reading.

Test for helminths ova:

1. The remaining volume of homogenized sample after the 100 ml was taken, was left in

the beaker to settle overnight,

2. The supernatant was siphoned off to just above the settled layer of solids,

3. The settled material in the beaker was mixed by swirling and poured into 100 ml

centrifuged tubes,

4. The beaker was rinsed two or three times and rinsing poured into 100 ml centrifuge

tubes,

5. The tube were balanced and centrifuged at 1250 RPM for 6 min,

6. The supernatant was poured off and pellet re-suspended thoroughly in Zinc Sulfate

Heptahydrate (1.2)

7. Zinc Sulfate Heptahydrate was centrifuged at 1250 PPM for 3 min,

8. The Zinc Sulfate Heptahydrate supernatant was poured into a 500 ml flask, diluted

with deionize water, covered and allowed to settle 3 hr. or overnight,

9. The supernatant was aspirated off to just above settled material,

48

10. The sediment was re-suspended by swirling an pipetted into conical centrifuge tubes,

11. The flask was rinsed with deionized water two to three times and rinse water pipted

into tubes,

12. Tubes were centrifuged at 1400 RPM for 6 min,

13. Pellets were combined into one tube and centrifuged at 1400 RPM for 6 min,

14. Pellets were re-suspended in acid alcohol solution and proceeded as previously in the

protozoan cysts procedure.

NB. Some steps were amendment according to lab, instruments, and samples conditions, as we

increased the time of centrifuging to 6 minutes in order to prevent sediments from losing in the

supernatant, especially if the sample is liquid and has minor sediments.

3.10 Data Entry and Analysis

After the experimental work and filling the questionnaire were finished. Data entry was done

using SPSS (Statistical Package for Social Science) software version 21.

Firstly data cleaning was done to detect the missing values, to ensure integrity and reliability

and to ensure that all data entered accurately and in appropriate way. Data cleaning was

conducted through operating frequencies and descriptive statistics for all dependent and

independent variables. Frequencies tables were used to distribute the collected data and to

show samples characteristics. Inferential statistics were used to compare means of dependent

and independent variables. Chi square test was used to compare categorical variables, and t-

test or one way ANOVA test was used to compare to compare the relationship between the

categorical and numeric variables. The level of significance was set at a P value of less than

0.05.

3.11 Study Limitations

1. Asking farmers to provide three consequently three stools samples at least in the two

rounds decreased the farmers response and this affected on the participants number.

2. Existence of maintenance works in GWWTP delayed TWW discharge for the exposed

group for four months, this disrupted the time line of the proposed study.

3. Unavailability of some chemicals in Gaza strip as Zinc Sulfate Heptahydrate.

4. High cost of chemicals and field work.

49

5. Limited capacity of Gaza laboratories especially for detection the parasites in the

environmental samples.

6. Low academic qualification for most participants had put extra effort on researcher to

explain the research requirements for them more than one time.

7. Some participants asked the researchers many times to give them an incentives,

register them in agriculture associations, and to provide them by irrigation facilities.

50

CHAPTER IV

Results and Discussion

This chapter presents the main findings which collected by the experimental analysis of stool,

soil, irrigation water, and hand washing water samples in the two study phases and the

interview questionnaire. This chapter includes the analysis results of lab experiments, then

descriptive statistics of the questionnaire data (percentage and frequency distribution)

including socio-demographic characteristics, housing characteristics, agricultural overview,

water and sanitation status, animals and birds breeding, and farmer's hygiene behavior, and

health status, and finally the data inferential analysis which used to illustrate the effect of

Hygiene behavior and parasitic infection risk factors on Parasitic infection among farmers, as

all relationships were done between HB and other independent variables were for finding a

justification for existence a parasitic infection.

The results of this study could help the researcher in raising and suggesting suitable

recommendations to reduce the parasitic infection among farmers in GS.

4.1. Study Participants

The number of participants in this study was 55 farmer. Participants were distributed

according to the source of the used irrigation water into two groups of farmers: MWUs and

GWUs, as shown in table and figure (4.1).

The number of MWUs, farmers who are using the TWW and GW, was 36; while the number

of GWUs, farmers who are using the GW only, was 19.

Table 4.1: Distribution of the study participants by the source of the used irrigation

water

Variable

Category

Total

Figure (4.1): Study

participants distribution

Number Percentage

Irrigation water

source

Mixed water (MW)

(TWW and GW)

Groundwater (GW)

36

19

65.5 %

34.5 %

Total

55

100%

TWWusers

GWusers

34.5%

65.5%

51

MWUs represented about two thirds of study participants (65.5%), while the GWUs

represented one third of study participants (34.5%). Number of participants depend on the

total number of farmers in the study areas and their response to participate in the study.

4.2. Collected Samples Analysis Results

4.2.1. Stool, soil, irrigation water (GW), and hand washing water samples analysis results

in the first phase:

Regarding stools samples analysis results in the first phase, it was found (17) participants had

parasitic infection; about (10) (58.8%) of the infected participants were from the MWUs

group, while (7) (41.1%) were from the GWUs group.

Five parasites species were identified in stool samples as follow, Cryptosporidium, Entamoeba

histolytica/dispar, Microsporidia, Giardia lamblia, and Strongyloides setercoralis

It was found (54.5%, 7.3% & 41.7%) of soil, irrigation water (GW), and hand washing water

samples respectively had parasitic contamination as per table (4.2).

4.2.2. Stool, soil, irrigation water (GW & TWW), and hand washing water samples

analysis results in the second phase:

Regarding stools samples analysis results in the second phase, it was found (26) participants

had parasitic infection; about (18) (69.2%) of the infected participants were from the MWUs

group, while (8) (30.7%) were from the GWUs group.

Five parasites species were identified in stool samples, Entamoeba ''histolytica/dispar and

Coli'', Cryptosporidium, Microsporidia, Giardia lamblia, and Ascaris lumbricoides.

It was found (61.5%, 0.001% &2.6) of soil, irrigation water (GW, TWW), and hand washing

water samples respectively had parasitic contamination as per table (4.2). Comparison

between results of the 1st and the 2

nd phases by figures is shown in Annex (12).

52

Table 4.2 Distribution of the study participants based on samples analysis results in the

two phases

#

Variable

Category

1st Phase 2

nd Phase

Total Total

Number % Number %

1. Stool results Infected

Non-infected

17

38

30.9%

69%

26

19

47.3%

52.7%

2. Parasitic

Species

Entamoeba histolytica/dispar cyst 2 11.8% 7 12.7%

Cryptosporidium sp. (Oocyst) 6 35.3% 6 10.9%

Giardia lamblia cyst 1 1.8%

Microsporidia sp. (Oocyst) 3 17.6% 2 3.6%

Cryptosporidium sp. (Oocyst) and

Microsporidia sp. (Oocyst) 1 1.8%

Entamoeba coli cyst, Giardia lamblia

cyst and Microsporidia sp. (Oocyst) 1 1.8%

Entamoeba histolytica/dispar cyst and

Cryptosporidium sp. (Oocyst) 1 5.9% 2 3.6%

Entamoeba histolytica/dispar cyst and

Giardia lamblia cyst 2 11.8% 3 5.5%

Entamoeba histolytica/dispar cyst and

Microsporidia sp. (Oocyst) 2 11.8% 1 1.8%

Entamoeba histolytica/dispar cyst,

Ascaris lumbricoides, and

Cryptosporidium sp. (Oocyst)

1 1.8%

Entamoeba histolytica/dispar cyst,

Entamoeba coli cyst and

Cryptosporidium sp. (Oocyst)

1 1.8%

S. setercoralis larvae, Cryptosporidium

sp. (Oocyst), and Microsporidia sp.

(Oocyst)

1 5.9%

3. Soil samples

results

Positive

Negative 30

25

54.5%

45.5%

32

20

61.5%

36.4%

4. Irrigation

water results

Positive

Negative 4

51

7.3%

92.7%

55 100%

5. Hand

washing

water results

Positive

Negative 5

7

41.7%

58.3%

1

38

2.6

97.4

53

It was found that the multiple parasitic infection in the 1st phase was observed in (6) (35.2%) s,

while (11) (64.7%) of the infected participants had single parasitic infection. In the 2nd

phase

the multiple parasitic infection was observed in (10) (38.5%) of the infected participants,

while (16) (61.5%) of the infected participants had single parasitic infection as shown in figure

(4.2).

Figure (4.2): Multiple and single infection at the infected participants in the two study phases

4.2.3. Wastewater characteristics through study period:

It's worth to mention that, through the irrigation period by TWW, wastewater samples were

taken from the GWWTP inlet, outlet, and from the outlet of the post WWT system for

monitoring the parasitic contamination as shown in the table (4.3). No parasitic contamination

was revealed in treated wastewater samples that were taken from outlet of the post WWT

system. All detected parasites are found in Annex (13).

Table 4.3: Wastewater characteristics through study period

Time

Sample source

pH

EC

TSS

(mg/l)

BOD5

(mg/l)

Parasitic

contamination

First month

GWWTP inlet 8.5 3300 550 430 Positive

GWWTP outlet 8.3 3280 200 140 Positive

Post WWT system outlet 8 3500 70 25 Negative

Second

month

GWWTP inlet 8.3 3220 1147 480 Positive

GWWTP outlet 8.5 3100 220.2 110 Positive

Post WWT system outlet 6.3 3400 81.6 32 Negative

Third

month

GWWTP inlet 8 3220 558 440 Positive

GWWTP outlet 7.79 3240 587.6 220 Positive

Post WWT system outlet 8.93 3770 253.6 25 Negative

0

5

10

15

20

Multipul infection Single infection

1st Phase

2nd phase

54

4.3. Parasitic Prevalence

4.3.1. Parasitic infection prevalence among participants:

4.3.1.1. Parasitic infection prevalence in the first phase:

At the 1st phase, based on odds ratio calculations in table (4.4); the overall prevalence of

parasitic infection at participants was (30.9%), The parasitic infection prevalence between

MWUs and GWUs were (27.8%), (36.8%) respectively (OR=0.659, CI (0.202-2.153),

negative association, not statistically significant) as shown in figure (4.3). This prevalence

results were more than the intestinal parasites prevalence among farmers from Bait-Lahia,

Gaza strip (18.6%) by using wet mount method; may be the differences occurred as result of

using the Modified Ziehl-Neelsen technique (acid-fast stain) in this study that detected the

infection by Cryptosporidium sp. and Microsporidia sp. (A. Al-hindi et al., 2013).

Figure (4.3): Parasitic infection at the first phase

The prevalence of the five parasites species that found in stool samples in the 1st phase were as

follows Cryptosporidium was the predominant recognized genus with a prevalence of

(14.5%) followed by Entamoeba histolytica/dispar, Microsporidium, Giardia lamblia cyst,

and Strongyloides setercoralis larvae with a prevalence of (12.7%), (10.9%), (3.63%),

(1.81%) respectively as shown in figure (4.5,a). The first predominant identified genus in this

study at the 1st phase was in agreement with a study carried out in GS that revealed the

Prevalence of parasitic infection (1st)

MWUs

GWUs

36.4

27.8% 10

7

0

2

4

6

8

10

12

MWUs GWUs

Number of infected participants (1st)

MWUs

GWUs

55

Cryptosporidium oocysts was the first predominant identified genus as its found in 62

(14.9%) of 416 child who attends Al-Nasser Hospital (A. I. Al-Hindi et al., 2007).

Table 4.4: Parasitic infection prevalence between farmers group in the first round

Diseased (Parasitic

infected)

Non-disease(non-

parasitic infected)

Total

Exposed 10 26 36

Non-exposed 7 12 19

Total 17 38 55

OR=

=

= 0.659 (0.202-2.153) (negative association, not statistically significant)

Total parasitic Prevalence in the first round =

Prevalence of parasitic infection between MWUs =

Prevalence of infection between GWUs =

4.3.1.2. Parasitic infection prevalence in the second phase:

At second phase, based on odds ratio calculations in table (4.5) the overall parasitic infection

prevalence of participants increased to became (47.3 %). The prevalence between MWUs and

GWUs were (50%), (42.1%) respectively (OR=1.37, CI (0.448-4.21), Positive association, not

statistically significant) as shown in figure (4.4).

Figure (4.4): Parasitic infection at the second phase

Prevelance of parasitic infection (2nd)

MWUs

GWUs

50%

42.1%

18

8

0

5

10

15

20

MWUs GWUs

Number of infected participants (2nd)

MWUs

GWUs

56

The prevalence of the five parasites species that found in stool samples at the 2nd

phase were

as follows Entamoeba histolytica/dispar/coli was the predominant identified genus with a

prevalence of (25.4%) followed by Cryptosporidium, Microsporidium, Giardia lamblia cyst,

and Ascaris lumbricoides with a prevalence of (18.1%), (9.1%), (5.45) (1.81) respectively as

shown in figure (4.5,b).

Table 4.5: Parasitic infection prevalence between farmers in the second round

Total Non-diseased Diseased

36 18 18 Exposed

19 11 8 Non-exposed

55 29 26 Total

OR=

=

= 1.37 (0.448-4.21) (Positively association, not statistically significant)

Total parasitic Prevalence in the first round =

Prevalence of parasitic infection between MWUs =

Prevalence of infection between GWUs =

Figure (4.5,a): Parasites prevalence in stool

samples at the 1st phase

Figure (4.5,b): Parasites prevalence in stool

samples at the 2nd

phase

Figure (4.5): Parasites prevalence in stool samples at the two phases.

Cryptosporidium

sp. (Oocyst);

14.5%

E. histolytica/dispar

cyst; 12.7 %

Microsporidium sp. (Oocyst);

10.9%

G. lamblia cyst; 3.6%

S. setercoralis larvae;

1.8%

Parasites prevalence in stool samples at the 1st phase

Cryptosporidium

sp. (Oocyst)

30%

E. histolytica/dispar

cyst 43%

Microsporidium

sp. (Oocyst)

15%

G. lamblia

cyst 9%

Ascaris lumbricoi

des 3%

Parasites prevalence in stool samples at the 2nd phase

57

According to the above odds ratio calculations, we revealed the prevalence of PI between

MWUs were higher than the PI between GWUs after three months study through it MWUs

used the TWW in irrigation, while the GWUs used GW and there is a positive not statically

significant association between the PI prevalence and using treated wastewater in irrigation.

4.3.1.3. Parasitic infection comparison between GWUs and MWUs:

Chi- square test revealed that there is no statically significant difference in the PI prevalence

between the two groups at two phases and between the group itself.

Table 4.6: Parasitic infection comparison between GWUs and MWUs in the two phases

by using Chi-square:

#

Variable

Parasitic infection (1st) Person

chi-

square

P

value Positive Negative

Freq. Row % Freq. Row %

1. Irrigation water

type

MWUs

GWUs

10

7

27.8

36.8

26

12

72.2

63.2

0.478

0.489

#

Variable

Parasitic infection (2nd

) Person

chi-

square

P

value Positive Negative

Freq. Row % Freq. Row %

2. Irrigation water

type

MWUs

GWUs

18

8

50

42.1

18

11

50

57.9

0.311

0.577

#

Variable

Parasitic infection (2nd

) between MWUs Person

chi-

square

P

value

Positive Negative

Freq. Row % Freq. Row %

3. Parasitic

infection (1st)

between MWUs

Positive

Negative

6

13

60

46.2

4

14

40

53.8

0.554

0.457

#

Variable

Parasitic infection (2nd

) between GWUs Person

chi-

square

P

value

Positive Negative

Freq. Row % Freq. Row %

4. Parasitic

infection (1st)

between GWUs

Positive

Negative

2

6

28.6

50

5

6

71.4

50

0.833

0.361

* The relationship or difference is statistically significant at P value < 0.05

58

Similar study was done in India by Sehgal & Mahajan (1991) and showed there is no

significant difference between prevalence of intestinal parasites and Giardia infection among

agricultural workers using untreated wastewater or treated wastewater compared with controls

who did not irrigate with wastewater (Sehgal & Mahajan, 1991), in addition to another study

revealed there is no excess risk was found in individuals exposed to untreated wastewater

compared with controls (OR 1.07, 95% CI 0.84–1.36); the group using reservoir water was not

different from the controls (OR 1.22, 95% CI 0.94–1.58) (Cifuentes, et al., 2000). A non-

compatible study with our results showed an increased risk of intestinal nematode infection

and hookworm infection, in particular, in wastewater farmers (OR= 31.4, 95% CI 4.1-243) and

their children (OR=5.7, 95% CI 2.1-16) when compared with farming households using

regular (non-wastewater) irrigation water (Ensink, et al., 2005)

In spite of MWUs HB was better than GWUs HB, their soil were less parasitic contaminated,

and they used localized irrigation technique ''drip irrigation system'' that offer them the most

health protection because the wastewater is applied directly to the plants, the high parasitic

infection between them may be attributed to two possibly reasons a) About 80% of participant

within age group ≤ 18 year were from MWUs group; another study revealed that the parasite

load of Ascaris infection was much higher among children living in wastewater-exposed areas

than unexposed areas (Al Salem & Abouzaid, 2006); b) Increasing soil organic matter in

MWUs soil after using TWW for three months lead to increasing soil microorganisms activity

and survival and then the PI opportunities. It was found the soil organic matter increased for

good contents after irrigation with well water, while excellent content obtained with irrigation

with treated wastewater (Al-Sbaihi et al., 2013). Another study showed the presence of

organic matter extends the survival of total and fecal coliforms, and Helminth eggs. In

addition to its reported that the wastewater application to soil generally raises activity of soil

microorganisms by increasing soil organic matter and it‘s a condition to pose an actual risk

from using TWW in agriculture either an effective dose of an excreted pathogen reaches the

field or the pathogen multiplies in the field to form an infective dose (WHO, 1989) (Toze,

1997).

4.3.2. Prevalence of some parasitic species:

It was found the OR value for Entamoeba histolytica/dispar/coli and Giardia lamblia

prevalence increased to be more than one in the second phase meaning there is a positive

59

association between prevalence of Entamoeba histolytica/dispar/coli and Giardia lamblia and

irrigation water type.

Table 4.7: Prevalence of E. histoltical/dispar/coli in the second round

Total Non-diseased by

E. histoltical/dispar/coli

Diseased by

E. histoltical/dispar/coli

36 25 11 Exposed

19 14 5 Non-exposed

55 39 16 Total

OR=

=

= 1.23 (0.401-3.776) (Positively association, not statistically significant)

Table 4.8: Prevalence of G. lamblia in the second round

Total Non-diseased by

G. lamblia

Diseased by

G. lamblia

37 31 6 Exposed

20 19 1 Non-exposed

57 50 7 Total

OR=

= 1.51 (0.401-3.776) (Positively association, not statistically significant)

OR calcualtions revealed that infection by Entamoeba histolytica/dispar/coli and Giardia

lamblia are the most wastewater related waterborne diseases. Crittenden et al. 2005 as cited in

((Roy et al., 2007)) revealed the protozoans associated with waterborne disease mainly include

Entamoeba histolytica, Entamoeba dispar, Giardia lamblia, and Cryptosporidium parvum.

4.3.3. Soil parasitic contamination prevalence:

4.3.3.1. Soil parasitic contamination prevalence in the first phase:

Based on table (4.9) soil parasitic contamination prevalence in the 1st phase was (54.5%). The

soil parasitic contamination prevalence at MWUs and GWUs were (52.8%), (57.9%)

respectively (OR= 0.813, CI (0.265-2.495), negative association not statistically significant) as

shown in figure (4.6).

60

Figure (4.6): Parasitic contamination in soil, irrigation water, and hand washing water

samples at the first phase

Table 4.9: Relationship between soil parasitic contamination and irrigation water type in

the 1st phase

Parasitic contaminated

soils

Non-parasitic

contaminated soils

Total

Exposed to TWW 19 17 36

Non-exposed to TWW 11 8 19

Total 30 25 55

OR=

=

= 0.813 (0.265-2.495) (negative association, not statistically significant)

Total soil parasitic contamination prevalence in the first round =

Prevalence of soil parasitic contamination at MWUs =

Prevalence of soil parasitic contamination at GWUs =

4.3.3.2. Soil parasitic contamination prevalence in the second phase:

At the second phase, the soil parasitic contamination prevalence increased to became (61.5%).

The soil parasitic contamination prevalence at MWUs and GWUs were (60.6%), (68.4%)

respectively (OR=0.897, CI (0.280-2.87), negative association, not statistically significant) as

shown in figure (4.7) and table (4.10). A study in Kumasi was not compatible with us and

Soil contamination with parasities prevalence (1st)

MWUs

GWUs

52.8%

57.9% 0

2

4

6

8

10

12

14

16

18

20

MWUs GWUs

Number of contaminated samples

Soil samples(1st)

Irrigationwater samples(1st)

Hand washingwater samples(1st)

61

revealed wastewater irrigated plots had higher numbers of coliforms and helminth counts than

those obtained from the potable water irrigated (Kwashie, 2011).

Figure (4.7): Parasitic contamination in soil, irrigation water, and hand washing water

samples at the second phase

Table 4.10: Relationship between soil parasitic contamination and irrigation water type

in the 2nd

phase

Parasitic

contaminated soils

Non parasitic

contaminated soils

Total

Exposed to TWW 20 13 33

Non-exposed to TWW 12 7 19

Total 32 20 52

OR=

=

= 0.897 (0.280-2.87) (negative association, not statistically significant)

Total soil parasitic contamination prevalence in the second round =

Prevalence of soil parasitic contamination at MWUs =

Prevalence of soil parasitic contamination at GWUs =

4.3.3.3. Relationship between soil samples results and other factors:

Chi-square test as per table (4.11) revealed that the percentage/prevalence of contaminated

soils were slightly higher at GWUs, and the relationship between soil parasitic contamination

and irrigation water source (farmers' group) was not statically significant. In addition to Chi-

Soil contamination with parasities prevaleance (2nd)

MWUs

GWUs

63.2%

60.6% 0

5

10

15

20

25

MWUs GWUs

Number of contaminated samples

Soil samples(2nd)

Irrigationwatersamples (2nd)

Hand washingwatersamples (2nd)

62

square test revealed there is astatically significant difference in soil parasitic contamination

prevalence between the two phases (P=0.042); as the prevalence of parasitic contamination

increased from 54.5% in the 1st phase to 61.5% in the 2

nd phase. But there was no statistically

significant difference between the soil parasitic contamination prevalence in the same group

between the two phases.

Table 4.11: Relationship between soil samples results and other factors

1. Relationship between soil parasitic contamination and irrigation water type

#

Variable

Soil parasitic contamination Person

Chi

square

P

value Positive Negative

Freq. Row % Freq. Row %

1.

Farmers' group MWUs(1st) 19 52.8 17 47.2

0.131

0.47 GWUs 11 57.9 8 42.1

2.

Farmers' group MWUs (2nd

) 20 60.6 13 36.1

0.033

0.855 GWUs 12 63.2 7 36.8

2. Relationship between soil parasitic contamination in the 2nd

phase and the soil parasitic

contamination in the 1st phase

#

Variable

Soil parasitic contamination (2nd

) Person

Chi

square

P

value Positive Negative

Freq. Row

%

Freq. Row

%

1.

Soil parasitic

contamination

(1st)

Positive 15 50 15 50

3.98

0.042

* Negative 17 77.3 5 22.7

3. Relationship between soil parasitic contamination in the 2nd

phase and the soil parasitic

contamination in the 1st phase at MWUs

#

Variable

Soil parasitic contamination (2nd

)

(MWUs)

Person

Chi

square

P

value

Positive Negative

Freq. Row

%

Freq. Row

%

1.

Soil parasitic

contamination

(1st) (MWUs)

Positive 10 52.6 9 47.4

1.19

0.275 Negative 10 71.4 4 23.5

Total 20 60.6 13 39.4

4. Relationship between soil parasitic contamination in the 2nd

phase and the soil parasitic

contamination in the 1st phase at GWUs

#

Variable

Soil parasitic contamination (2nd

)

(GWUs)

Person

Chi

square

P

value

Positive Negative

Freq. Row

%

Freq. Row

%

1.

Soil parasitic

contamination

(1st ) (GWUs)

Positive 5 45.5 6 54.5

3.51

0.061 Negative 7 87.5 1 12.5

Total 12 63.2 7 36.8

* The relationship or difference is statistically significant at P value < 0.05

63

4.4. Relationship Between Parasitic Contamination In the Collected Samples

(Soil, Irrigation Water, and Hand Washing Water) And Parasitic Infection

4.4.1. Relationship between soil parasitic contamination and parasitic infection:

A statistically significant relationship was found between soil parasitic contamination and

stool parasitic in the first phase only (P=0.029), may be this because the percentage of

participants who within the age group ≤ 18 year who had negative/non contaminated soils

increased from 32% in the first phase to 45% in the second phase, see Annex (14).

Table 4.12: Relationship between soil samples results and parasitic infection

#

Variable

Stool parasitic infection (1nd

) Person

Chi

square

P

value Positive Negative

Freq. Row % Freq. Row %

1.

Soil parasitic

contamination

(1st )

Positive 13 43.3 17 56.7

4.77

0.029* Negative 4 16 21 84

Total 17 30.9 38 69.1

#

Variable

Stool parasitic infection (2nd

) Person

Chi

square

P

value Positive Negative

Freq. Row % Freq. Row %

1.

Soil parasitic

contamination

(2nd

)

Positive 12 37.5 20 62.5

2.50

0.113 Negative 12 60 8 40

Total 24 46.2 28 53.8

* The relationship or difference is statistically significant at P value < 0.05

4.4.2. Relationship between irrigation water samples and hand washing water results and

parasitic infection:

Chi-square test revealed there is no statically significant relationship between irrigation water

and hand washing water samples results and parasitic infection.

64

4.5 Descriptive Statistics of the Interview Questionnaire

4.5.1. Socio-demographic characteristics of the study participants:

As shown in table (4.13) all participants were mainly from two areas which were Al-Zaitoun-

next to Gaza car shop and Al-Zaitoun-Abu maeali district; most of the MWUs were from the

first area (49.1%) and most of the GWUs were from the second area (27.3%); the other

participants (23.7%) were from different areas (Joher El-Deek, Asqola, Salah El-Deen street,

and El-Shiekh Ejleen). Males (83.6%) were more represented in this study than females

(16.4%) because males in the two study areas mainly work in agriculture and females only

provide the assistance at need. The age of farmers divided into three main groups, the majority

of farmers were distributed equally at age group ≤ 18 year (38.2%) and 19-46 year (38.2%),

farmers at age group ≥ 46 year represented the least group (23.6%). According to family size

participants were divided into two groups ≤ 7 members and ≥ 8 members; (56.4 %) of them

had 8 members and above. Around half of participants (50.9%) had preparatory or general

secondary, (40%) had primary school and less, and the other had high studies (9.1%). The

financial and economic status for participants were as follows (23.6%) excellent, (12.7%) very

good, (41.8%) good, and (21.8%) bad.

Table 4.13: Distribution of the study participants by socio-demographic characteristics

#

Variable

Category

Total

Number Percentage

1.

Farmer's address Al-Zaitoun, Gaza car shop

Al-Zaitoun, Abu maeali

Other areas

27

15

13

49.1%

27.3%

23.7%

2. Gender Male

Female

46

9

83.6%

16.4%

3. Age ≤18 year

19-45 year

≥ 46 year

21

21

13

38.2%

38.2%

23.6%

4. Family Size ≤ 7 members

≥ 8 members

24

31

43.6%

56.4%

5. Academic qualification Primary School and less

Preparatory and General

Secondary

Bachelors/Diploma/High studies

22

28

5

40%

50.9%

9.1%

6. Financial and economic status Excellent

Very Good

Good

Bad

13

7

23

12

23.6%

12.7%

41.8%

21.8%

65

4.5.2. Housing characteristics of the study participants:

As shown in table (4.14) most of participants had concrete building homes (94.5%); only

(5.5%) of participants had asbestos building homes. Most of participants are living in a

populated areas as the distance between homes of (89.1%) participants were ≤ 30 meters.

Regarding participants home land type, (72.7%) of participants' home land were covered by

court, while (27.3%) of participants their home land were covered by court and some areas

were not courted but were covered by concrete or soil (landless). Most of participants are

living in a weak infrastructural areas, as (90.9%) of them live in unpaved streets ''have soil

around their homes''; the other participants (9%) have paved streets, or paved streets but there

is soil or grass areas around their homes.

Table 4.14: Distribution of the study participants by housing characteristics

#

Variable

Category

Total

Number Percentage

1. Farmer's home type Concrete

Asbestos

52

3

94.5%

5.5%

2. Distance between farmer's home and the

closest neighbor

≤ 30 meters

≥ 31 meters

49

6

89.1%

10.9%

3. Type of farmer's home land Court

others (court and concrete /

court and soil)

40

15

72.7%

27.3%

4. Type of the land around farmer's home Soil

Others (concrete, grass, or

concrete and soil)

50

5

90.9%

9%

4.5.3. Agriculture overview of the study participants:

As shown in table (4.15); more than half of participants (52.7%) worked mainly as a farmers;

while (47.3%) didn‘t work mainly as farmers, since (57.6%) of them were students. High

percentage of participants (90.9%) worked in their agricultural lands with assistants, as their

family members share/assist them (father, mother, sons, brothers, sisters, wives, and husband);

participants reported the working in agriculture need assistance especially in planting and

harvesting periods, so they ask help from their family members and if they cannot secure

sufficient number from them they ask help from non-relatives people.

Regarding the distance between participants home and their agricultural lands (23.6%) of

participants lived in the farm, (27.3 %) lived beside or close to their farm; while (49.1%) of

66

participants lived far away from their farms. Living in or beside farm means approximately

there is a good access to toilet and washing facilities at need

Participants' daily spent time in the farm divided into two groups; (61.8%) of participants

spent ≤ 6 hours per day in working in agriculture; while (38.2%) spent ≥ 7 hours per day. Also

the years of working in agriculture divided into two groups; (58.2 %) of participants worked

in agriculture for period of ≥ 11 year; while (41.8%) worked in agriculture for period of ≤10

year. Regarding area of participants farm (58.2%) of them had ≥ 4 dunums; while the other

participants (45.5%) had ≤ 3 dunums. Through irrigation by GW 92.7% of participants used

fertilizers procured from shops in Gaza or from their or other farms, they frequently used

birds, chemical, animals respectively.

Using TWW in the first study area (Al-Zaitoun area) began in 2004; (63.9%) of MWU's

participants were new users for TWW as they used it only from 2-5 years; while (36.1%) were

used it for a period of ≥ 6 years. In spite of the fertility advantage for TWW (25%) of MWU's

used fertilizers through irrigation by TWW periods, the other participants used it sometimes or

at need. All MWU's reported that they are eating the irrigated plants by TWW, all of them stop

the irrigation by TWW before two weeks from harvesting, and they used the TWW for

irrigation olive, citrus, and fruits trees.

67

Table 4.15: Distribution of the study participants by agricultural practices

characteristics

#

Variable

Category

Total

Number Percentage

1. Farming is the main job for

participant

Yes

No

29

26

52.7%

47.3%

2. Years of working in agriculture ≤10 years

≥ 11 years

23

23

41.8%

58.2%

3. Farmer works with assistants in

his/her farm

Yes

No

50

5

90.9%

9.1%

4. Farm address Home exists inside farm

Farm beside/close to farmer's home

Farm is far away from farmer's

home

13

15

27

23.6

27.3

49.1

5. Daily spent time in the farm ≤ 6 hours

≥ 7 hours

34

21

61.8%

38.2%

6. Farm area ≤ 3 dunums

≥ 4 dunums

25

30

45.5%

54.5%

8. Using fertilizers Yes

Sometimes

51

4

92.7%

7.3%

9. Area of the agricultural lands that

irrigated by TWW

≤ 3 dunums

≥ 4 dunums

15

12

41.7%

58.3%

11. Years of using TWW in agriculture 2 – 5 years

≥ 6 years

23

13

63.9%

36.1%

12. Eating plants that irrigated by

TWW

Yes 36

100%

13. Using fertilizes through irrigation

by TWW periods

Yes

Sometimes "at need"

No

9

14

13

25%

38.9%

36.1%

4.5.4. Water status of the study participants:

As shown in table (4.16), all participants depend on the desalination water plants for drinking

water. For non-drinking water purposes (56.4%) of participants used municipal water wells,

(25.5%) used agricultural water wells, (18.2%) used more than one source as the municipal

and agricultural water wells or municipal and private wells.

All participants reported that, they use the desalinated water directly without doing anything as

chlorination, filtration, boiling, or other techniques in order to ensure the water is free from

microbiological contamination.

68

Table 4.16: Distribution of the study participants by water status characteristics

#

Variable

Category

Total

Number Percentage

1 Drinking water source Private water plants

(Desalination water plant)

55

100%

2 Non-drinking water source Municipality water

Agricultural water wells

More than one source

(municipal and agricultural

water wells or municipal and

private wells)

30

15

10

56.4%

25.5%

18.2%

4.5.5. Sanitation status of the study participants:

As illustrated in table (4.17) most participants (76.7%) disposed their toilet wastewater into

sewage network, (9.1%) pumped it directly to their farm, and (14.5%) used cesspits exist

beside their homes . About (60%) of participants had toilet in their farm; (72.7%) of them

discharged farm toilet wastewater into septic tanks constructed under the toilet and the other

(27.3%) discharged it directly into the farm. It was found (66.7%) of participants who had no

toilet in their farm used their home toilet at need, while (21.2%) urinated between plants, and

(12.1%) urinated on the edge of the farm. About (81.8%) of participants who had toilet in their

farm avail an easy access to toilet to other farmers.

Table 4.17: Distribution of the study participants by sanitation status characteristics

#

Variable

Category

Total

Number Percentage

1. Sanitation disposal place of home's

toilet

Pumped to the Farm

Pumped to cesspits

Pumped to WW network

5

8

42

9.1%

14.5%

76.7%

2. Having toilet in the farm Yes

No

22

33

40%

60%

3. Other farmers share your farm's

toilet

Yes

No

18

4

81.8%

18.2%

4. Sanitation disposal place of farm's

toilet

Pumped to the farm

Pumped to septic tanks

6

16

27.3%

72.7%

5. Urinating place for farmers who

have not toilet in the farm

Home

between plants

On the edge of the farm

22

7

4

66.7%

21.2%

12.1%

69

4.5.6. Birds and animals breeding of the study participants:

It obvious from table (4.18); breeding birds or animals is a common habit between farming

communities, as (89.1%) of participants were breeding birds or animals, 87.7% of them were

breed the birds/animals inside or beside their home. About (49%) of participants who breed

birds/animals were using closed place for the birds/animals, (32.7%) were not using closed

place, and (18.4%) were not using closed place at all times. From the farmers who breed

birds/animals (67.3%) were using the remaining plants for feeding the birds and animals,

(44.9%) were breeding birds only, (20.4%) were breed cattle, and (34.7%) of them were breed

more than one species birds/cattle, birds/cattles/cats, or birds/cats.

Table 4.18: Distribution of the study participants by bids and animals breeding

characteristics

#

Variable

Category

Total

Number Percentage

1. Breeding birds and/or animals Yes

No

49

6

89.1%

10.9%

2. Place of breeding birds and/or animals Inside/beside home

In the farm

43

6

87.7%

12.3%

3. Birds and animals exist in closed place Yes

Sometimes

No

24

9

16

49%

18.4%

32.7%

4. Birds and animals eat the agricultural

remaining

Yes

Sometimes

No

33

4

12

67.3%

8.2%

24.5%

5. Birds and animals species Birds

Cattle

More than one species

(birds/cattle,

birds/cattles/cats, or

birds/cats)

22

10

17

44.9%

20.4%

34.7%

4.5.7. Hygiene behavior of the study participants:

Hygiene behavior (HB) of the study participants divided into three types/models: HB. for

participants inside their homes, HB. for participants through harvesting process, and HB. for

participants through working in the farm, as illustrated in tables (4.19.1,2&3).

Regarding HB. for participants inside their homes (table (4.19.1)), it was found (76.4%) of

participant families consumed ≤ 3 soap piece/week, while (23.6%) of them consumed 4-7 soap

piece/week. Participants divided into three categories regarding cooking place; about (63.6%)

70

of them cooked in their home kitchen, (5.5%) cooked outside their home, (30.9%) cooked

outside the home and sometimes cooked inside it in the kitchen. It was found that (63.6%) of

participants always wore shoes when they going out around their home, while (14.5%),

(9.1%), and (12.7%) were almost, rarely, and never wear shoes when they going out

respectively.

Table 4.19.1: Distribution of the study participants by hygiene behavior inside \ home

characteristics

#

Variable

Category

Total

Number Percentage

1. Soap consumption in home ≤ 3 peace/family. week

4-7 peace/family. week

42

13

76.4%

23.6%

2. Cooking place In the home kitchen

Outside the home

In the home kitchen and

outside the home

35

3

17

63.6%

5.5%

30.9%

3. Wearing shoes when going out

around home

Always

Almost

Rarely

Never

35

8

5

7

63.6%

14.5%

9.1%

12.7%

Regarding HB. for participants through harvesting process, it was found that through irrigation

by GW periods, HB. for MWUs were better than the HB. for GWUs in dealing with crops that

fall on soil if they want to eat it. While the GWUs were better than MWUs in dealing with

crops that fall on soil through harvesting process if they want to put it in boxes for consumers

selling.

It was found the HB. for MWUs in dealing with crops that fall on soil through harvesting

process were improved when they used TWW in irrigation.

71

Table 4.19.2: Distribution of the study Participants by hygiene behavior through

harvesting process

# Variable

Participants

Get rid

them

Wash them

very well

Clean it by

using my

hands or

my clothes

Eat them

directly/

collect it

Mean RII

*

1.

At harvest, how

do you deal with

fruits that fall on

soil if you want to

eat it

GWUs (GWIP) 0 1 16 2 1.94 49

MWUs (GWIP) 0 11 17 8 2.08 52

MWUs

(TWWIP) 0 5 19 7 3.52

88

2.

At harvest, how

do you deal with

fruits that fall on

soil if you want to

sell it

GWUs (GWIP) 16 0 0 3 3.87 97

MWUs (GWIP) 30 1 0 1 1.93 48

MWUs

(TWWIP) 26 1 0 1 3.85

96

*Relative importance index

Regarding HB. for participants through working in the farm, it was found that through

irrigation by GW periods, frequency of using the faucet that existed in the farm for washing

had taken the highest score at the two farmer groups (95%, GWUs), (66%, MWUs), while

washing hands after touching the irrigation water had taken the lowest score also at the two

farmer groups (25%, GWUs), (32%, MWUs).

It was found that, through irrigation by TWW, washing hands after touching the irrigation

water had taken the highest score (68%), while wearing gloves and special clothes had taken

the least score (35%).

72

Table 4.19.3: Distribution of the study participants by hygiene behavior through

working in farm characteristic

# Variable

Participants

Always Almost Rarely Never Mean RII

1. Existence soap in

the farm

GWUs (GWIP) 13 0 2 4 3.26 82

MWUs (GWIP) 5 0 9 22 1.91 48

2. Frequency of using

the faucet

GWUs (GWIP) 16 2 1 0 3.78 95

MWUs (GWIP) 3 15 9 2 2.65 66

3.

Washing hands by

using used water

for multiple times

GWUs (GWIP) 0 0 0 19 1 25

MWUs (GWIP) 0 2 0 34 1.11 28

4.

Washing fruits and

vegetables before

eating them

GWUs (GWIP) 10 1 1 7 2.73 68

MWUs (GWIP) 7 13 4 12 2.41 60

MWUs (TWWIP) 13 4 3 11 2.61 65

5.

Washing hands

after operating the

irrigation pump

GWUs (GWIP) 2 0 1 16 1.36 34

MWUs (GWIP) 4 3 0 7 1.75 44

MWUs (TWWIP) 6 4 0 14 2.08 52

6.

Washing hands

after maintaining

any faults in water

irrigation network

GWUs (GWIP) 5 2 1 11 2.05 51

MWUs (GWIP) 7 1 4 12 2.12 53

MWUs (TWWIP) 10 2 1 8 2.66 67

7.

Washing hands

when they had

touch soil

GWUs (GWIP) 2 1 0 16 1.42 36

MWUs (GWIP) 3 4 0 29 1.47 37

MWUs (TWWIP) 4 2 0 25 1.51 38

8.

Touching with the

irrigation water

GWUs (GWIP) 14 4 1 0 3.68 92

MWUs (GWIP) 9 5 18 4 2.52 63

MWUs (TWWIP) 6 2 14 9 2.16 54

9.

washing after

Touching with the

irrigation water

GWUs (GWIP) 0 0 0 19 1 25

MWUs (GWIP) 3 0 1 32 1.27 32

MWUs (TWWIP) 13 4 3 9 2.72 68

10.

Wearing special

footwear through

working in the field

GWUs (GWIP) 3 2 7 7 2.05 51

MWUs (GWIP) 4 4 7 21 1.75 44

MWUs (TWWIP) 6 3 6 16 1.96 49

11.

Wearing gloves

when you work in

the field

GWUs (GWIP) 1 0 5 13 1.42 36

MWUs (GWIP) 1 0 7 28 1.27 32

MWUs (TWWIP) 2 0 7 22 1.41 35

12.

Wearing special

clothes when you

work in the field

GWUs (GWIP) 13 0 0 0 3.05 76

MWUs (GWIP) 7 0 6 23 1.75 44

MWUs (TWWIP) 2 0 6 23 1.38 35

*Relative importance index

73

4.5.8. Health status of the study participants:

As illustrated in table (4.20.1); about (54.5%) of participants had not been diagnosed for

intestinal parasites in their life, only (45.5%) of them did, (44%) of them were diagnosed for

intestinal parasites through their childhood, (20%) were frequently diagnose for intestinal

parasites as (every year , six months, or four months), the others (36%) were non frequently

diagnose. About (72%) of participants received anti-parasitic drugs after diagnosis, (20%)

didn‘t treated by anti-parasitic drugs after diagnosis, and about (8%) were sometimes treated

by anti-parasitic drugs after diagnosis. There were three Participants mentioned they

previously had infected by the Ascaris lumbricoides and two other farmer families complain

from Enterobius vermicularis infection.

Regarding health status; about (61.8%) of participants informed they had excellent health

status, (23.6%) had good health status, (14.3%) had acceptable health status. All MWU's

informed their health status didn‘t differ after using TWW in irrigation.

Regarding farmers' children health status, (51.2%) of participants informed their children

health status is excellent, while the others informed as follows; (29.3%) good, (9.8%)

acceptable, and (9.8% ) bad. About (95.5%) from MWUs informed their children health status

didn‘t differ after using TWW in irrigation, the other MWUs informed they can't evaluate their

children health after using TWW.

About (72.2%) of participants informed the using TWW in agriculture increases the disease

infection, (38.2%) of them informed the infection happened if the farmer touch the TWW, if

the TWW was bad quality, or if the farmer doesn‘t take suitable precautions.

74

Table 4.20.1: Distribution of the study participants by health status characteristics

#

Variable

Category

Total

Number Percentage

1. Have you ever been diagnosed with

intestinal parasites

Yes

No

25

30

45.5%

54.5%

2. When/How you had been diagnosed

with intestinal parasites

Childhood

Frequently

Non- frequently

11

5

9

44%

20%

36%

3. Having previously anti-parasitic

drugs

Yes

No

Sometimes

18

5

2

72%

20%

8%

4. Farmers' health status Excellent

Good

Acceptable

Bad

34

13

18

0

61.8%

23.6%

14.3%

0

5. Farmers' children health status Excellent

Good

Acceptable

Bad

21

12

4

4

51.2%

29.3%

9.8%

9.8%

6. Using TWW in agriculture increased

your diseases infection

Yes

No

I do not know

Yes, if farmers touch it, if it

has bad quality, or if farmer

does not take suitable

precautions

19

11

21

4

34.5%

20%

7.3%

38.2%

Abnormal stool with blood (100%) and abnormal vomiting (96%) were the least self-reported

symptoms at GWUs. While abnormal stool with blood (100%) and abnormal diarrhea (97%)

were the least self-reported symptoms at MWUs.

Abnormal abdominal pain (75%), abnormal diarrhea (79%), and abnormal loss of appetite

(79%) were the most self-reported symptoms at GWUs. While the same symptoms excluding

abnormal diarrhea were the most self-reported symptoms at MWUs (84%) and (85%)

respectively.

75

Table 4.20.2: Distribution of the study participants by farmers' self-reported symptoms

# Variable FG Yes

Sometimes

No Mean RII

1. Suffering from abnormal

diarrhea

GWUs 5 2 12 2.36 79

MWUs 0 3 33 2.91 97

2. Suffering from abnormal

constipation

GWUs 5 1 3 2.42 81

MWUs 2 5 29 2.75 92

3. Suffering from abnormal

abdominal pain

GWUs 7 0 12 2.26 75

MWUs 6 5 25 2.52 84

4. Suffering from abnormal stool

with blood

GWUs 0 0 19 3 100

MWUs 0 0 36 3 100

5. Suffering from abnormal

vomiting

GWUs 1 0 18 2.89 96

MWUs 3 4 29 2.72 91

6. Suffering from abnormal

fever

GWUs 2 1 16 2.73 91

MWUs 1 3 32 2.86 95

7. Suffering from abnormal

weakness

GWUs 3 1 1.5 2.63 88

MWUs 2 2 32 2.83 94

8. Suffering from abnormal

headache

GWUs 5 1 13 2.42 81

MWUs 5 2 29 2.66 89

9. Suffering from abnormal loss

of appetite

GWUs 6 0 13 2.36 79

MWUs 6 4 24 2.55 85 *Highest RRI mean there are low self-reported symptoms.

76

4.6 Inferential Statistics of the Interview Questionnaire

4.6.1. Socio-demographic factors

As shown in table (4.21&22); Chi-square test revealed that the highest parasitic infection was

among females (33.3%) compared to males (30.4%) but no statistically significant difference

was found (P=0.863), in the same time there were a statistically significant differences

between mean of HB and gender (P=0.001), as the HB mean of males were (1.65) more than

the HB mean of females (1.05). This result was compatible with study was carried in Iran that

showed there is no statically significant difference in parasitic infection (PI) between males

and females (p=0.177) (Kiani et al., 2016); and with another study revealed that the parasites

were slightly more common in females (54.7%) than males (41.7%) (Sinniah et al., 2012), but

it was non-compatible with study was carried in Turkey on children of farm workers that

showed there is a statically significant difference between parasitic infection and gender (Doni

et al., 2015).

ANOVA test and Chi-square test revealed there is no statistical significant relationship

between PI or HB with participants age (P= 0.107), however; the participants were in age

group ≤18 year had the highest PI percentage (42.9%) and the least HB mean (1.27). It was

found a compatible study with our results that revealed the parasites were more common in

age groups from (1-20) (Sinniah, et al., 2012).

Chi-square test revealed that there is a statistical significant difference (p=0.04) between PI

and family size, as the farmers' families who had ≥ 8 members were hosting parasites more

than the other group who had ≤ 7 members. Another study showed the family size

significantly associated (p=0.044) with the intestinal parasitic infection (Tulu et al., 2014).

Regarding academic qualification, our results showed that there is no statistically significant

association between HB or PI with academic qualification of the participants (P ≥ 0.05), while

the PI was the highest and HB mean was the least between participants who had primary

school and less. A study on risk factors of intestinal parasitic infection between prisoners

showed compatible results, as it revealed the level of education was inversely related to the

risk of intestinal parasites infection where the post primary education prisoners were least

infected with intestinal parasites infection when compared to unschooled prisoners, but the

relationship wasn‘t statically significant (P =0.07) (Rop et al., 2016). In addition to another

study was compatible with our result as it revealed that the inhabitant with higher education

77

background had significantly lower infection rates of Ascaris and Trichuris (Toma et al.,

1999).

Regarding farmers' financial and economic status, Chi-square revealed there is no statically

significant relationship between financial and economic status and PI, but the highest PI was

found between participants who had bad financial and economic status, in addition a

statistically significant association was found between participants financial and economic

status and HB (p=0.005); Post hoc test showed that the main statistical significant was found

among participants who had good financial and economic status and participants who had

excellent financial and economic status; as stated in another study the effect of poverty on the

intestinal parasitic infection is complex and could be attributed to many factors, such as an

unhygienic environment, lack of safe potable water, protective clothes, and poor nutrition; as

many studies conducted in different countries showed that parasitic infections were higher in

those with a low socioeconomic status and was more common among immigrants (Doni, et al.,

2015). Another study found that people from households with an average socio-economic

status had a much higher risk of E. histolytica infection compared with those from households

with a good socioeconomic status (p=0.01) (Duc et al., 2011).

Table 4.21: Relationship between socio-demographic factors and parasitic infection

#

Variable

Parasitic Infection (1st phase) Pearson

Chi-

square

P

value

Positive Negative

Freq. Row % Freq. Row %

1. Gender Male 14 30.4 32 69.6

0.03

0.863 Female 3 33.3 6 66.7

2.

Age

≤18 year 9 42.9 12 57.1

4.46

0.107

19-45 year 3 14.3 18 85.7

≥ 46 year 5 38.5 8 61.5

3. Family Size ≤ 7 members 4 16.7 20 83.3 4.04 0.040*

≥ 8 members 13 41.9 18 58.1

4.

Academic

qualification

Primary School and

less 9 40.9 13 59.1

3.33

0.188

Preparatory and General Secondary

8 28.6 20 71.4

Other(Bachelors/Diplo

ma/High studies) 0 0 5 100

5.

Financial and

economic

status

Excellent 4 30.8 9 69.2

6.03

0.110

Very Good 1 14.3 6 85.7

Good 5 21.7 18 78.3

Bad 7 58.3 5 41.7

* The relationship or difference is statistically significant at P value < 0.05

78

Table 4.22: Relationship between socio-demographic factors and hygiene behavior

# Variable Category N Mean SD Factor Value P

value

1.

Hygiene behavior

Gender

Male

Female

46

9

1.64

1.05

0.807

0.110

t

4.74

0.001

*

2. Age

≤18 year

19-45 year

≥ 46 year

21

21

13

1.27

1.69

1.76

0.552

0.790

0.949

F

2.33

0.107

3. Family Size

≤ 7 members

≥ 8 members

24

31

1.51

1.58

0.928

0.637

t

-0.317

0.753

4. Academic qualification

Primary School and less

Preparatory and General

Secondary

Other

(Bachelors/Diploma/High

studies)

22

28

5

1.37

1.69

1.5

0.739

0.834

0.353

F

1.08

0.345

5. Financial and economic status

Excellent

Very Good

Good

Bad

13

7

23

12

1.53

1.92

1.41

1.55

0.742

0.893

0.606

0.770

F

4.83

0.005

*

* The relationship or difference is statistically significant at P value < 0.05

4.6.2. Housing factors:

As illustrated in table (4.23); all housing factors were found not statistically significant with

the parasitic infection. It's worth to mention that the parasitic infection between farmers who

had landless areas inside their homes (covered by soil) (33.3%) were higher than the PI

infection of farmers who had not landless areas and all their homes area are covered by court

(30%). Also the parasitic infection between farmers who had areas covered by (concrete,

grass, or concrete & soil) around their homes (40%) were higher than the PI between farmers

who had only sandy areas around their homes (30%). Studies found the soil contact is a mode

of geo-helminths transmission (Amenu, 2014), and there is a statistically significant

relationship (p < 0.05) between PI and population who live in cardboard-tin, wooden house,

or dirt floor (Basualdo et al., 2007).

79

Table 4.23: Relationship between Housing factors and parasitic infection

# Variable Parasitic Infection (1st phase) Pearson

Chi-

square

P

value

Positive Negative

Freq. Row % Freq. Row %

1.

Farmer's

home type

Concrete Asbestos 17

0

32.7

0

35

3

67.3

100

1.42

0.233

Total 17 30.9 38 69.1

2.

Type of

farmer's home

land

Court others (court & concrete

/ court & soil)

12

5

30

33.3

28

10

70

66.7

0.057

0.812

Total 17 30.9 38 69.1

3.

Land type

around

farmer's home

Soil Others (concrete, grass,

or concrete & soil)

15

2

30

40

35

3

70

60

0.213

0.645

Total 17 30.9 38 69.1

* The relationship or difference is statistically significant at P value < 0.05

4.6.3. Agricultural factors:

As illustrated in table (4.24& 4.25); Chi-square test revealed there is no statistically significant

relationship between working in agriculture and the parasitic infection (p=0.573), but the

parasitic infection was least in participants who work mainly as farmers, may be this because

(73.1%) of participants who didn‘t work mainly in agriculture were within age group ≤18 year

(the group that had least HB mean and highest PI), Annex (14) shows the relationship between

age groups and other variables. In addition it was found a statistically significant differences

between HB and participants job (p=0.047), as the HB for participants who work mainly as

farmers was better than the HB for participants who didn‘t work mainly in agriculture. Our

study was non-compatible with study that revealed the E. histolytica infection in people who

work in agricultural higher than people who work in non-agricultural work (p=0.7) (Duc, et

al., 2011), and compatible with another study that showed the occupation has an important

influence on hookworm epidemiology, as the hookworm infection has been noted to be more

common in families who are involved with agricultural pursuits (Brooker et al., 2004).

The relationship between years of working in agriculture and PI was not statically significant

(p=0.087), but we found higher PI percentage between the participants group who had work in

agriculture for period of ≤ 10 years, may be this because the HB mean for them was less than

the HB mean for other group who had work in agriculture for period of ≥ 11 years, may this

attribute to existence (82.6%) from participants who work in agriculture for period of ≤10

80

years were within the age group ≤18 year (the group that had least HB mean and highest PI),

see Annex (14).

It was found there is no statically significant relationship between daily working hours in the

farm with PI and HB (P value= 0.266, 0.768 respectively). The HB mean for participants who

work in their farm ≤ 6 hours per day was less than the other group who work ≥ 7 hours per

day, this may effect on their parasitic infection as we found higher PI percentage between the

participants group who had least HB mean; may be this was also for the same previous reason,

as (52.9%) from participants who work in their farm ≤ 6 hours per day were within the age

group ≤18 year (the group that had least HB mean and highest PI), see Annex (14).

The parasitic infection between participants who work/had farm far away from their homes

was the highest, but the relationship was not statically significant (p=0.904), in the same time

the relationship between HB and farm address was not statically significant (p=0.424). The

HB mean for farmers participants who had the farms inside their homes was the best; may be

this because they had good access for water and home toilet.

The relationship between using fertilizers and PI was not statistically significant (p=0.391).

Our result was compatible with study that showed handling animal excreta in the field had a

significantly lower risk for an E. histolytica infection than those who have no contact with

animal excreta. But it's worth to mention that several points are important with regard to this

result since the animals do not harbour E. histolytica infections and it is rarely found in

domestic animals, including dog and cat (Duc, et al., 2011).

81

Table 4.24: Relationship between agricultural factors and parasitic infection

#

Variable

Parasitic infection (1st phase) Pearson

Chi-

square

P

value Positive Negative

Freq. Row % Freq. Row %

1. Is farming your

main job

Yes 8 27.6 21 72.4

0.317

0.573 No 9 34.6 17 65.4

2. Years of working

in agriculture

≤10 years 10 43.5 13 56.5

2.92

0.087 ≥ 11 years 7 21.9 25 78.1

3. Farm address Home exists inside farm 4 30.8 9 69.2

0.201

0.904

Farm beside/close from

farmer home 4 26.7 11 73.3

Farm is far away from

farmer home 9 33.3 18 66.7

4. Area of the

agricultural lands

≤ 3 dunums 9 36 16 64

0.556

0.456 ≥ 4 dunums 8 26.7 22 73.3

4. Using fertilizers Yes 15 29.4 36 70.6

0.736

0.391 Sometimes 2 50 2 50

5. Daily spent time

in the farm

≤ 6 hours 11 32.4 23 67.6

0.087

0.768 ≥ 7 hours 6 28.6 15 71.4

* The relationship or difference is statistically significant at P value < 0.05

Table 4.25: Relationship between agricultural factors and hygiene behavior

# Variables N Mean SD Factor Value P

value

1.

Hygiene behavior

Is farming your main job

Yes

No

29

26

1.74

1.33

0.864

0.595

t

2.03

0.047*

2. Years of working in

agriculture

≤10 years

≥ 11 years

23

32

1.27

1.75

0.51

0.866

t

-2.56

0.013*

3. Farm address

Home exists inside farm

Farm beside/close from

farmer home

Farm is far away from

farmer home

13

15

27

1.73

1.35

1.57

0.753

0.596

0.859

F

0.872

0.424

4. Daily spent time in the

farm

≤ 6 hours

≥ 7 hours

34

21

1.44

1.71

0.623

0.956

t

-1.13

0.266

* The relationship or difference is statistically significant at P value < 0.05

82

4.6.3.1. Using TWW in agriculture:

Parasitic infection between new MWUs (who use the TWW for period of 2 – 5 years ) was

higher than old MWUs (who use the TWW for ≥ 6 years) but the relationship was not

statistically significant, may be this because the new MWUs are not aware or experienced in

dealing with TWW as the old MWUs. Chi-square test revealed that (56.5%) of MWUs (who

use the TWW for period of (2 – 5 years) were within age group ≤18 year (the group had PI

and the least HB mean) and t-test revealed they have HB mean less than the HB mean for the

other group. See Annex (14).

In the same time the PI between MWUs who used the TWW for irrigation ≥ 4 dunums

agricultural lands was higher than the PI between MWUs who used the TWW for irrigation ≤

3 dunums, but the relationship was not a statically significant; may be this attributed to the

high exposure for contaminated agricultural soils. Number of MWUs' who use fertilizers with

TWW was 23 out of 36, the relationship between using fertilizers in combination of irrigation

with TWW was not statistically significant with PI, but it's worth to mention that least PI was

found between famers who didn‘t use fertilizers through using TWW in irrigation.

Table 4.26: Relationship between period of using TWW in agriculture factors and

parasitic infection

#

Variable

Parasitic infection between

MWUs only

Pearson

Chi-

square

P value

Positive Negative

Freq. Row % Freq. Row %

1. Years of using TWW in

agriculture

2 – 5 years 8 34.8 15 65.2

1.55

0.212 ≥ 6 years 2 15.4 11 84.6

Total 10 27.8 26 72.2

2. Area of the agricultural

lands that irrigated by

TWW

≤ 3 dunums 4 26.7 11 73.3 0.556 0.456

≥ 4 dunums 6 28.6 15 71.4

0.016

0.900 Total 10 27.8 26 72.2

3. Using fertilizers through

irrigation by TWW

Yes 3 33.3 6 66.7

0.286

0.867 No 3 23.1 10 76.9

Sometimes, at

need 4 28.6 10 71.4

Total 10 27.8 26 72.2

* The relationship or difference is statistically significant at P value < 0.05

83

4.6.4.Water status:

All participants were found using one source of drinking water which was desalinated water

plants. Water studies in Gaza revealed that more than 90% of the population of the Gaza strip

depend on desalinated water for drinking purposes (Al-Agha & Mortaja, 2005). It's worth to

mention that in 2016 an assessment of parasitological water quality from house kitchens and

desalination plants filters in Gaza Strip found that a total of 8 (1.9%) out of 420 samples of

various drinking water sources in were contaminated by Cryptosporidium oocysts (Ghuneim

& Al-Hindi, 2016).

Regarding non-drinking water sources, as shown in table (4.27) there is no statistically

significant relationship between the non- drinking water sources and PI. Other researchers

revealed there was a direct relation between the prevalence of some parasitic diseases and the

presence of those etiologic agents in water (Yousefi et al., 2010). In Gaza strip researches

found the total and fecal coliform contamination exceeded the World Health Organization's

limit for drinking water purposes. However, the contamination percentages were higher in

domestic water networks than in GW wells. In the same time the diarrheal diseases were

strongly correlated with fecal coliform contamination in water networks (r = 0.98). Such

diseases were more prevalent among subjects who drank municipal water than subjects who

drank desalinated or home-filtered water (odds ratio = 2.03) (Amr & Yassin, 2008).

The non-drinking water consumption (Liter/person. day) calculated based on participants

family size and the total non-drinking water consumption per day for each participants'

families. Pearson correlation revealed there is no statistically significant relationship between

HB and non-drinking water consumption (Liter/person. day). However, the direction of the

relationship was positive meaning that these variables tend to increase together, but the

magnitude, or strength, of the association is approximately none or very weak.

The mean of non-drinking water consumption (Liter/person. day) for parasitic infected

participants was less than the mean of non-drinking water consumption (Liter/person. day) for

non-parasitic infected. Our study was compatible with the study was carried in Ethiopia that

revealed the prevalence of diarrhoea among under- 2-year-olds from families with higher

water usage rates per person was less than that among comparable children from families with

lower rates (Freij & Wall, 1977), and with another study in Lesotho that revealed the use of

84

smaller amounts of water was associated with higher rates of infection with Giardia lamblia

(Esrey et al., 1989).

Table 4.27: Relationship between water status and parasitic infection

1. 1. Relationship between non- drinking water source and parasitic infection

#

Variable

Parasitic infection (1st phase) Person chi

square

P

value Positive Negative

Freq. Row % Freq. Row %

1.

non-

drinking

water source

Municipality water 9 30 21 70

0.525

0.769

Agricultural water well 4 26.7 11 73.3

more than one source 4 40 6 60

Total 17 30.9 38 69.1

2. 2. Effect of non-drinking water consumption (Liter/person. day) on farmers hygiene behavior

Variable Mean SD Factor Value P value

Farmers behavior 1.55 0.77 Pearson

Correlation

0.072

0.602 Water consumption (Liter/person.day) 135.3 72.9

3. 3. Effect of non-drinking water consumption (Liter/person. day) on farmers parasitic infection

Variable Category N Mean SD Factor Value P value

Water

consumption

(Liter/person.day)

Parasitic infection

Positive

Negative

17

38

119.7

142.3

33.5

84.3

t

-1.42

0.160

* The relationship or difference is statistically significant at P value < 0.05

4.6.5. Sanitation status:

The relationship between home toilet sanitation disposal method and PI was not statistically

significant (P=0.197); however, the highest PI was between participants who disposed their

homes' toilet sanitation by discharging it for their farms; Chi-square test revealed that there is

a statically significant relationship between farm address and sanitation disposal method, as all

of participants who disposed their homes' toilet sanitation by discharging it for farms had the

farm inside their home; and this may be increased their exposure for sanitation and then

increased their PI. Some mortality studies reported that the method of disposing of excreta

determined the magnitude of the health impact (Anker & Knowles, 1980; Haines & Avery,

1982; Waxler et al., 1985). A longitudinal cohort study in Salvador, Brazil, found that an

85

increase in sewerage coverage from 26% to 80% resulted in a 22% reduction of diarrhoea

prevalence in children under 3 years of age (Mara et al., 2010). Other studies revealed that the

absence of correct body waste material disposal and the lack of drinking water or its

inadequate supply are risk factors associated to the presence of intestinal parasites (Basualdo,

et al., 2007). In addition to it was found that the E. histolytica infection in people who have

dry latrine (single or double vault) was higher than water latrine (septic tank, biogas) (Duc, et

al., 2011).

The relationship between existence a toilet in the farm and PI was not statistically signification

(P=0.634); however, the highest PI was between farmers who didn‘t have toilet in their farms;

this was compatible with studies showed that having access to a sanitation facility reduces the

odds of being infected with soil-transmitted helminths regardless of the species (Ziegelbauer et

al., 2012).

The relationship between sharing farm toilet and PI was not statistically significant, this result

was non- compatible with another study that revealed the sharing or using public latrine

statistically associated with intestinal parasitic infection (Tulu, et al., 2014).

The relationship between disposal methods of farm's toilet sanitation and PI was not

statistically significant with high PI between participants who use cesspits, chi-square revealed

that all of them work in farms far away from their homes and this effect on their access to

water and hygiene facilities.

86

Table 4.28: Relationship between sanitation status and parasitic infection

#

Variable

Parasitic infection (1st phase) Person chi

square

P value

Positive Negative

Freq. Row % Freq. Row %

1.

Home's

toilet

sanitation

disposal

place

Pumped to the Farm 3 60 2 40

3.25

0.197 Pumped to septic

tank 1 12.5 7 87.5

Pumped to WW

network 13 31 29 69

Total 17 30.9 38 69.1

2. Do you have

toilet in the

farm

Yes 6 27.3 16 72.7

0.227

0.634 No 11 33.3 22 66.7

Total 17 30.9 38 69.1

3. Do other

farmers

share with

you the

farm's toilet

Yes 4 22.2 14 77.8 No 2 50 2 50

1.273

0.259

Total 17 30.9 38 69.1

4. Farm's toilet

sanitation

disposal

place

Pumped to the farm 0 0 6 100 Pumped to septic

tank 6 37.5 10 62.5

3.09

0.079

Total 6 27.3 16 72.7

#

Variable

Farm address

Person chi

square

P value

Home

exists

inside

farm

Farm

beside/close

from farmer

home

Farm is far

away from

farmer

home

Freq. Row

%

Freq. % Freq. Row

%

1.

Home's

toilet

sanitation

disposal

place

Pumped to the Farm 5 10

0

0 0 0 0

20.247

0.010*

Pumped to septic

tank 3 37.

5

2 25 3 37.5

Pumped to WW

network 5 11.

9

13 31 24 57.1

Total

2.

Variable

Home exists

inside farm

Farm is far away

from farmer home

Person chi

square

P value

Freq. Row % Freq. Row %

Farm's toilet

sanitation

disposal

place

Pumped to the Farm 3 50 3 50

9.263

0.002* Pumped to septic

tank 0 0 16 100

Total 3 13.6 19 86.7

* The relationship or difference is statistically significant at P value < 0.05

87

4.6.6. Breeding birds and/or animals:

The relationship between breeding animals/birds, place of breeding, and place situation

(closed or non-closed) were not statistically significant with PI. However, the highest PI was

between participants who breed animals/bird in non-closed place inside or beside their farm.

Studies revealed that the close contact with domestic animals in household increase the E.

histolytica infection (p=0.003 ) (Duc, et al., 2011).

Table 4.29: Relation between breeding birds and/or animals and parasitic infection

#

Variable

Parasitic infection (1st phase) Person

chi

square

P

value Positive Negative

Freq. Row % Freq. Row %

1.

Breeding birds

and/or animals

Yes 16 32.7 33 67.3

0.64

0.424 No 1 16.7 5 83.3

2. Place of breeding

birds and animals

inside/beside home

13 30.2 30 69.8

0.639

0.333 inside / beside

farm 3 50 3 50

3. The breeding birds

and animals exist in

closed place

Yes 7 29.2 17 70.8

1.47

0.479 No 7 43.8 9 56.3

Sometimes 2 22.2 7 77.8

* The relationship or difference is statistically significant at P value < 0.05

4.6.7. Hygiene behavior

4.6.7.1 Effect of farmers' hygiene behavior inside home on parasitic infection

There was a statically significant relationship between soap consumption in participants'

homes and PI (p=0.041), the PI between participants' families who consumed 4-7 soap peace

per week was higher than participants' families who consumed ≤ 3 soap peace per week; chi-

square revealed that 86.6% of participants' families who consumed 4-7 soap peace.week were

large families (≥ 8 members) and as we mentioned before the PI between them was higher

than the PI between the small families (≤ 7 members). Mean of soap consumption per

participant per week determined based on family size for each participant and family soap

consumption per week; it was found that the average soap consumption is 0.38 peace per

week. According to sphere standard, a minimum standards for humanitarian response, at least

250g (2-3 peace) of soap should be available for personal hygiene per person per month, based

on that all participants soap consumption were under the standard consumption in emergency

(Sphere Project, 2011).

88

The relationship between cooking place and wearing shoes when participants move around

their homes were not statically significant with PI, this was not compatible with study that

revealed the not wearing a protective shoes (p < 0.001) was significantly associated with PI

(Tulu, et al., 2014).

Table 4.30: Effect of farmers hygiene behavior inside home on parasitic infection

#

Variable

Parasitic infection (1st phase) Person

Chi

square

P value

Positive Negative

Freq

.

Row % Freq. Row %

1.

Soap

consumption in

home

≤ 3 peace/family. week 10 23.8 32 76.2

4.19

0.041*

4-7 peace/family. week 7 53.8 6 46.2

2. Cooking place In the home kitchen 13 37.1 22 62.9

2.41

0.229

Outside the home 0 0 3 100

In the home kitchen

and outside the home

4

23.5 13 76.5

3. Wearing shoes

when going out

around home

Always 10 28.6 25 71.4

6.76

0.08 Almost 2 25 6 75

Rarely 4 80 1 20

Never 1 14.3 6 85.7

#

Variable

Family size Person

Chi

square

P value

≤ 7 members ≥ 8 members

Freq

.

Row % Freq. Row %

1. Soap

consumption in

home

≤ 3 peace/family. week 22 52.4 20 47.6

5.52

0.019* 4-7 peace/family. week 2 15.4 11 84.6

* The relationship or difference is statistically significant at P value < 0.05

4.6.7.1.1 Comparison hygiene behavior inside home between farmer groups:

HB inside home for MWUs was better than the HB for GWUs. It was found a statistically

significant difference between GWUs hygiene behavior inside home and MWUs in (1 out of

3) for MWUs benefit.

89

Table 4.31: Comparison hygiene behavior inside home between MWUs & GWUs

#

Variable

Parasitic infection (1st phase) Person

Chi

square

P

value MWUs GWUs

Freq. Row % Freq. Row %

1.

Soap

consumption

in home

≤ 3 peace/family. week 25 59.5 17 40.5

2.76

0.096

4-7 peace/family. week 11 84.6 2 15.4

Total 36 65.5 19 34.5

2. Cooking place In the home kitchen 26 74.3 9 25.7

7.22

0.027*

Outside the home 3 100 0 0

In the home kitchen

and outside the home

7

41.2 10 58.8

Total 36 65.5 19 34.5

3. Wearing shoes

when going

out around

home

Always 21 60 14 40

2.86

0.413 Almost 7 87.5 1 12.5

Rarely 4 80 1 20

Never 4 57.1 3 42.9

Total 36 65.5 19 34.5

* The relationship or difference is statistically significant at P value < 0.05

4.6.7.2. Effect of farmers' hygiene behavior through harvesting on parasitic infection

Chi-square test revealed there was no statically significant relationship between participant's

hygiene behavior through harvesting and parasitic infection.

4.6.7.2.1. Comparison of farmers' hygiene behavior '' through harvesting ''

Chi-square test revealed there is statically significant relationship between MWUs and GWUs

in dealing with fruits that fall on the soil if they want to eat it, as (30.6%) of MWUs wash it

before eating it directly while (5.3%) of GWUs wash it. Regarding MWUs HB through

harvesting when they use TWW; Chi-square test revealed there is statically significant

difference between MWUs behavior according to irrigation water type.

90

Table 4.32: Comparison hygiene behavior through harvesting between the two farmer

groups when they use GW

#

Variable

HB through harvesting if participants want to eat

fruits that fall on the soil

Person

-chi

square

P value

a b c

Freq. Row

%

Freq. Row

%

Freq

.

Row

%

1. MWUs 8 22.2 17 47.2 11 30.6

7.418

0.025* GWUs 2 10.5 16 84.2 1 5.3

a b c Person

chi

square

P value

(MWUs, GWIP)

(MWUs, TWWIP)

Freq. Row

%

Freq. Row

%

Freq

.

Row

%

2. Eat them 3 24.9 4 57.1 0 0

10.7

0.029*

Clean them by using my

hands or my clothes

2 10.5 10 52.6 7 36.8

Wash hem very well 1 20 0 0 4 80

#

Variable

HB through harvesting if participants want to sell

fruits that will fall on the soil

Person

chi

square

P value

d e f

Freq. Row

%

Freq. Row

%

Freq

.

Row

%

3. MWUs 1 3 1 3 31 93.9

3.452

0.178 GWUs 3 16.7 0 0 15 83.3

d e f Person

chi

square

P value

(MWUs, GWIP)

(MWUs, TWWIP)

Freq. Row

%

Freq. Row

%

Freq

.

Row

%

4. collect them 1 100 0 0 0 0

56

0.001* Wash hem very well 0 0 1 100 0 0

Get rid them 0 0 0 0 26 100

* The relationship or difference is statistically significant at P value < 0.05

a: Eat them, b: Clean them by using my hands or my clothes, c:Wash hem very well

d: collect them, e: Wash hem very well, f: Get rid them

91

4.6.7.3. Effect of farmers hygiene behavior inside farm on parasitic infection:

Generally we can say the hygiene behavior mean for participants who were parasitic infected

were less than the hygiene behavior mean for participants who were not parasitic infected

based on t-test results in the table (4.31).

Table 4.33: Effect of farmers hygiene behavior inside farm on parasitic infection:

Variable Category N Mean SD Factor Value P value

Hygiene

behavior

between

GWUs

Parasitic infection between GWUs (1

st)

Positive

Negative

7

12

1.78

1.54

1.14

0.864

t

0.487

0.637

Parasitic infection between GWUs (2

nd)

Positive

Negative

8

11

1.43

1.77

0.495

1.19

t

-0.839

0.415

Hygiene

behavior

between

MWUs

Parasitic infection between MWUs (1st)

Positive

Negative

10

26

1.2

1.62

0.421

0.707

t

-2.2

0.036*

Parasitic infection between MWUs (2

nd)

Positive

Negative

18

18

1.37

1.63

0.494

0.971

t

-1.2

0.239

* The relationship or difference is statistically significant at P value < 0.05

4.6.7.3.1. Comparison hygiene behavior inside farm between farmer groups

Generally the HB inside farm mean for GWUs was higher than the HB inside farm mean for

MWUs. It was found a statistically significant difference between GWUs hygiene behavior

inside farm and MWUs in (4 out of 12 ) for GWUs benefit and in (1 out of 12) for MWUs

benefit.

92

Table 4.34: Comparison hygiene behavior inside farm between MWUs & GWUs

#

Variable

Always Almost Really Never Person

Chi

square

P

value

F. Row %

F. Row %

F. Row %

F. Row %

1. Existence soap in the

farm

MWUs 5 13.9 9 25 22 61.1

16.8

0.001* GWUs 13 68.4 2 10.5 4 21.1

2. Frequency of using

farm faucet

MWUs 3 10.3 15 51.7 9 31 2 6.9

26.2

0.001*

GWUs 16 84.2 2 10.5 1 5.3 0 0

3. Washing hands by

using multiple used

water

MWUs 2 5.6 34 94.4

1.09

0.424 GWUs 0 0 19 100

4. Washing crops before

eating them

MWUs 7 19.4 13 36.1 4 11.1 12 33.3

9.5

0.022* GWUs 10 52.6 1 5.3 1 5.3 7 36.8

5. Washing hands after

operating irrigation

pump

MWUs 4 16.7 3 12.5 0 0 17 70.8

4.17

0.243

GWUs 2 10.5 0 0 1 5.3 16 84.2

6. Washing hands after

maintaining any

faults in farm

MWUs 7 29.2 1 4.2 4 16.7 12 50

1.95

0.582

GWUs 5 26.3 2 10.5 1 5.3 11 57.9

7. Washing hands after

touch soil

MWUs 29 80.6 4 11.1 3 8.3

0.554

0.758

GWUs 16 84.2 1 5.3 2 10.5

8. Touching irrigation

water

MWUs 4 11.1 18 50 5 13.9 9 25

16.7

0.001*

GWUs 0 0 1 5.3 4 21.1 14 73.7

9. Washing hands after

touching the

irrigation water

MWUs 32 88.9 1 2.8 3 8.3

2.27

0.320 GWUs 19 100 0 0 0 0

10

.

Wearing special

footwear in the field

MWUs 21 58.3 7 19.4 4 11.1 4 11.1

2.82

0.419

GWUs 7 36.8 7 36.8 2 10.5 3 15.8

11

.

Wearing gloves when

you work in the field

MWUs 28 77.8 7 19.4 1 2.8

0.626

0.731 GWUs 13 68.4 5 26.3 1 5.3

12

.

Wearing special

clothes when you

work in the field

MWUs 23 63.9 6 16.7 7 19.4

13.8

0.001*

GWUs 6 31.6 0 0 13 68.4

* The relationship or difference is statistically significant at P value < 0.05

Regarding MWUs hygiene behavior inside farm through irrigation by TWW; Paired samples t

test revealed there is a statistically significant relationship between HB inside farm for MWUs

and irrigation water type, as the mean for HB through irrigation by TWW was higher than the

HB mean through irrigation by GW as its found in table (4.35).

93

Table 4.35: Comparison MWUs hygiene behavior inside farm through irrigation by GW

and TWW

Variable Category N Mean SD Factor Value P value

HB between

MWUs

HB between MWUs

through (TWWIP)

HB between MWUs

through (GWIP)

36

36

1.70

1.41

0.92

0.66

t

2.7

0.01*

* The relationship or difference is statistically significant at P value < 0.05

In developing countries the intestinal parasitism was an indicator of substandard sanitation,

poor personal hygiene, lack of a convenient, safe water source, overcrowding, and poverty

(Glickman et al., 1999). A study in Nigeria revealed the prevalence of infection was

significantly higher in children who did not wash fruits before eating when compared to those

who did regularly wash (p=0.001), also the infection rate was significantly higher in children

who washed fruits irregularly when compared to those who did regularly (p=0.010). In

addition to the prevalence of infection was significantly higher in children who did not use

foot wear when compared to those who always did (p=0.001) and to those who did

occasionally (p=0.001). In addition to, the proportion with hookworm was higher among

children who did not use foot wears after school hours compared to consistent foot wear users.

Not wearing of foot wears after school was significantly associated with risk of acquisition of

intestinal helminthes (p=0.001) (Ilechukwu et al., 2010). A cross-sectional study about

associated risk factors of intestinal parasitic infections among primary school revealed that

students who had no frequent contact with water during swimming and irrigation activities

were found to be protected from intestinal parasitic infections compared to those who were

unable to do so (p=0.007) (Tulu, et al., 2014). Using personal protective conditions during

field work such as gloves and boots reduced the risk (OR = 0.5, 95% CI: 0.3-1.1) and omitting

to bath and shower after field work increased the risk (OR = 2.3, 95% CI: 1.0-5.6) for an

infection with E. histolytica. However, these associations were not statistically significant.

Omitting to wash hands was a significant risk as the people who rarely washed their hands

with soap after field work had a large risk increase of an E. histolytica infection (OR = 3.0,

95% CI: 1.2-7.4) compared to those who frequently wash their hand with soap after work

(Duc, et al., 2011).

94

4.6.8. Health status:

4.6.8.1. Relationship between farmers' knowledge and other factors:

ANOVA test revealed that the participants who had higher HB mean were more educated or

aware about risk of using TWW in agriculture, but the relationship between awareness and HB

and PI was not statistically significant as per table (4.36). Another study revealed the

prevalence of intestinal parasitic infection was high in communities of some areas however,

the knowledge of these communities about intestinal helminths and protozoa is low

(Nyantekyi et al., 2014).

Table 4.36: Relationship between farmers' knowledge and other factors

1. Relationship between farmers' knowledge by TWW risks and hygiene behavior

# Variables N Mean SD Factor Value P

value

1.1

Hygiene

behavior

Using TWW in agriculture increased your diseases infection

Yes

No

I do not know

Yes, with conditions*

19

11

21

4

1.88

1.29

1.33

1.81

0.944

0.6

0.639

0.239

F

2.46

0.073

2. Difference between farmers' knowledge by TWW risks and farmer group

# Variable Yes No I don‘t

know

Yes, with

conditions*

Person

chi-

square

P

value

F. Row

%

F. Row

%

F. Row

%

F. Row

%

2.1 Farmers'

group

MWUs 7 19.4 7 19.4 18 50 4 11.1

12.58

0.005*

GWUs 12 63.2 4 21.2 3 15.8 0 0

Total 19 34.5 11 20 21 38.2 4 7.3

3. Relationship between farmers' knowledge by TWW risks and parasitic infection

knowledge Positive

(1st) 6 35.3 2 11.8 7 41.2 2 11.8

1.57

0.664

Negative 13 34.2 9 23.7 14 36.8 2 5.3

Total 19 34.5 11 20 21 38.2 4 7.3

knowledge Positive

(2nd

) 11 42.3 5 19.2 8 30.8 2 7.7

1.59

0.660

Negative 8 27.6 6 20.7 13 44.8 2 6.9

Total 19 34.5 11 20 21 38.2 4 7.3

95

4.6.8.2. Relationship between participants those previously had diagnosed and taken

helminthic medicine with parasitic infection:

As illustrated in table (4.37), Chi-square test reveled there is no statistically significant

relationship between those previously had diagnosed for helminthic and PI, but the percentage

of participants who were not parasitic infected and in the same time who had previously

diagnosed for helminthic (76%).

Chi-square test revealed there is a statistically significant relationship between those had taken

helminthic medicine and the parasitic infection, as we found (83.3%) of participants who had

previously medicine were not infected. Study on four villages inhabitants in Indonesia

revealed there is no significant difference in Ascaris and Trichuris infection were observed

between those having received helminthic medicines and those without (Toma, et al., 1999).

Table 4.37: Relationship between participants those previously had diagnosed and had

taken helminthic medicine and parasitic infection:

#

Variable

Parasitic infection Person

Chi

square

P value

Positive Negative

Freq. Row % Freq. Row %

1.

Previously

diagnosed for

intestinal parasites

Yes 6 24 19 76

1.02

0.311 No 11 36.7 19 63.3

2. Previously had

ant-parasitic drugs

Yes 3 16.7 15 83.3

6.9

0.032*

No 1 20 4 80

Sometimes 2 100 0 0

* The relationship or difference is statistically significant at P value < 0.05

4.6.8.3. Relationship between farmers' self-reported symptoms and parasitic infection

and hygiene behavior:

Chi-square test revealed there is no statistically significant relationship between farmers' self-

reported symptoms and their infection. As the experimental analysis for stool samples

revealed that all detected parasites were cysts, in addition to there are some parasites have no

symptoms in some cases; for example, most people who infected with A. lumbricoides have no

symptoms (CDC, 2017b).

Regarding the relationship between self-reported symptoms and hygiene behavior; Pearson

correlation test revealed that there was a statistically significant linear relationship between

hygiene behavior and self-reported symptoms; the direction of the relationship is negative

96

meaning that if one variable increase the other variable will decrease (if the participant have

high self-reported symptoms score (participant didn‘t feel much in his/her parasitic infection),

his/her hygiene behavior will be less; the magnitude or strength of the association is

approximately moderate (0.3 < | r | < 0.5). In developing countries, the presence, incidence,

and prevalence of intestinal parasitic infections in different regions are indicators of the health

status of the population (Gamboa et al., 2003).

Table 4.38: Association between farmers' self-reported symptoms and hygiene behavior

Variable Mean SD Factor Value P value

Farmers Hygiene behavior

Parasitic infection symptoms

1.55

2.8

0.77

0.557

Pearson

Correlation

-0.45

0.001*

* The relationship or difference is statistically significant at P value < 0.05

97

Chapter V

Conclusions and Recommendations

This chapter provides the main conclusions of this study as well as recommendations for

decision makers that help to decrease parasitic infection between farmers, protect them, and

improve their health status.

5.1 Conclusions

1. PI between MWUs were higher than the PI between GWUs after using TWW for three

months.

2. Positive association not statically significant was found between using TWW in

irrigation and PI.

3. Six parasites species were identified at farmers in this study at the two phases

Entamoeba histolytica/dispar and coli, Cryptosporidium, Microsporidium, Giardia

lamblia, Strongyloides stercoralis, and Ascaris lumbricoides.

4. Cryptosporidium was the predominant recognized genus followed by Entamoeba

histolytica/dispar, Microsporidium, and Giardia lamblia in the first phase.

5. Entamoeba histolytica/dispar was the predominant recognized genus followed by

Cryptosporidium, Microsporidium, and Giardia lamblia in the second phase.

6. Positive not statically significant association was found between prevalence of

Entamoeba histolytica/dispar and Giardia lamblia and using TWW in irrigation in the

2nd

phase.

7. A statistically significant difference was found between soil parasitic contamination

prevalence in the two phases, as the prevalence of soil parasitic contamination

increased after using TWW for three months.

8. Negative association not statically significant was found between soil parasitic

contamination and irrigation water source.

9. Prevalence of parasitic contamination was higher at GWUs soils.

10. A statically significant relationship was found between soil contamination and PI at

participants in the 1st phase.

11. High PI was found between participants who had bad financially status, who had

landless areas inside their homes, who work in farm far away from their homes, who is

98

a new user for TWW and irrigate more agricultural dunums by it, who didn‘t work

mainly in agriculture, who use fertilizers with TWW, who had toilet in their farm, who

disposed from their home and farm toilet into the farm and cesspits respectively, who

breed animals/birds in places non- closed inside or beside their farms, who previously

diagnosed for intestinal parasites, and who had less HB mean.

12. MWUs HB was better than GWUs HB inside home and through harvesting process,

but it was less through working in farm. HB for MWUs through using TWW periods

increased to be the best.

13. It was found a statically significant relationship (SSR) between gender and financial

status with HB.

14. Highest HB mean was found between participants who work mainly in agriculture,

who had the farm inside their homes, and who more knowledgeable toward TWW risk.

15. The least HB and highest PI was found between females, participants who had the least

academic qualification, participants age ≤ 18 year, participants who were working in

agriculture for period of ≤10 years, and who work ≤ 6 hours per day in the farm.

16. SSR was found between family size and participants who previously had ant-parasitic

drugs with PI, as we found participants who had less family size and who previously

had ant-parasitic drugs had less PI.

17. A statically significant linear relationship was found between self-reported parasitic

symptoms and HB, as we found if participant feel good and the self-reported parasitic

symptoms were less, her/his HB will be worse.

18. Non-drinking water consumption per person per day was least at parasitic infected

participants.

19. All participants were depend on desalinated water plants as a source for drinking

water, non-drinking water consumption per person per day was least at patristic

infected participants, but the relationship was not statistically significant.

5.2 Recommendations

Protection of farmers and their families health can best be achieved by interrupts the flow of

pathogens from the environment (wastewater, crops, soil etc.) to them.

99

5.2.1. Study recommendation:

1. Improving levels of hygiene both occupationally and in the home and enhancing

farmers commitment in using protective clothes even if they use GW or TWW in

irrigation.

2. Farms should be provided with adequate water for drinking and hygiene purposes, in

order to avoid the consumption of, and contact with, wastewater as proper hand

washing with soap should be emphasized before eating anything especially when

farmers are working in the farm.

3. Reduction using animal and birds manure and replacing it by organic compost to

reduce the parasitic infection.

4. Performing regular screening programs for farming communities in parallel with

chemotherapy programmes to be reapplied at regular intervals to be effective as many

as 2–3 times.

5. A rigorous health education programme that targets consumers, farm workers, produce

handlers and vendors is needed.

6. An official licensed institution should be assigned to regular monitor tthr TWWR

projects and follow up the TWW quality and commitment of farms in using the

protective and barriers that put in order to interrupts the flow of pathogens from the

environment to them.

7. All above recommendation should be considered as health protection measures to be

used in conjunction with partial wastewater treatment.

5.2.2. Further research recommendations:

1. Conducting studies on the parasitic load in wastewater and effluent of post treatment

systems as (filtration and SAT).

2. Support and provide the GS laboratory with the required equipment for detection

parasites in water samples.

3. Conducting studies on the parasitic load in animals and birds manure.

4. Assessment WWR projects and farmers commitment by the using treated wastewater

in agriculture guidelines.

100

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108

Annexes

Annex (1): Wastewater networks in the Gaza Strip, source (CMWU, 2016)

Governorate Covering %

North 80

Gaza 90

Middle area 70

Khanyounis 40

Rafah 72

The overall ratio of wastewater coverage 72

Annex (2): Pathogens levels and diseases associated with untreated wastewater, source

(Ottoson, 2005; Toze, 1997)

Pathogen by Taxon Disease Concentration

in wastewater

Infectious

dose

Protozoans

Cryptosporidium Parvum Diarrhoea, fever

100-10

5

Low* Giardia intestinalis Giardiasis

Entamoeba histolytica Amoebiasis

(amoebic dysentery)

Helminths

Ascaris lumbricoides Ascarisis

100-10

5

Low* Enterobius vericularis Enterobiasis

Taenia saginata Taeniasis

Trichuris trichiura Trichuriasis

Strongyloides stercoralis Strongyloidasis

few*: few particles/cells/cysts/eggs required to cause infection. High*: many required to cause

infection.

109

Annex (3): Survival times of selected excreted pathogens in soil, wastewater and on crop

surfaces at 20-30oC, source (Faechem 1983)

Type of pathogen

Survival time (in days unless otherwise stated)

In soil On crops In wastewater

Protozoa

Entamoeba histolytica ˂20 but usually ˂10 ˂10 but usually ˂2 ˂30 but usually ˂15

Helminths

Ascaris lumbricoidies eggs. Many months ˂60 but usually ˂30 Many months

Hookworm larvae ˂90 but usually ˂30 ˂30 but usually ˂10

Taenia saginata eggs Many months ˂60 but usually ˂30

Trichuris trichiura eggs Many months ˂60 but usually ˂30

Annex (4): Wastewater reuse guidelines

Annex (4.1): Revised 1989 WHO guidelines for wastewater reuse in agriculture, source

(Blumenthal & Peasey, 2002)

Helminth

egg/L

Irrigation

method

Exposed group Reuse condition

≤ 0.1 Any Workers, consumers, and

public

Unrestricted: crops eaten

uncooked, sports fields,

public parks.

A

≤ 1 Spray / sprinkler Workers < 15 years B1 Restricted: cereal crops,

industrial crops, fodder crops,

pasture and trees

B

≤ 1 Flood/furrow Workers < 15 years B2

≤ 0.1 Any Workers including

children, nearby

communities

B3

Not

applicable

Trickle, drip, or

bubbler

None Localized irrigation of crops

in category B if exposure of

workers and the public does

not occur

C

110

Annex (4.2): Recommended guidelines for water reuse in the Mediterranean region

Helminth

(egg/L)a

TSS (mg/L) Recommended treatment

I ≤ 0.1 ≤ 10 Secondary + filtration + disinfection

II ≤ 0.1 ≤ 20, ≤ 150c Secondary + filtration + disinfection or

secondary + storage/ maturation

ponds/infiltration

III ≤ 1 ≤ 35, ≤ 150c Secondary + few days storage or

oxidation pond system

IV None As required by irrigation

technology

Minimum primary treatment

a: Does not require routine monitoring.

c: when treating with stabilization ponds.

Annex (4.3a): Criteria recommended by PWA for effluent standards in the Gaza Strip

Criteria Restricted Use Unrestricted Use

BOD (mg/l) 10-20 10-20

TSS (mg/l) 15-20 15-20

Total-N (mg/l) 10-15 10-15

F. coliforms < 1000 < 200

Helminthes eggs < 1 < 1

Intestinal nematoda < 1 ova/liter < 0.1 ova/liter

Notes:

Restricted crops: Cereal crops, industrial crops, fodder crops, crops normally eaten cooked and

trees, etc.

Unrestricted crops: Crops normally eaten uncooked (vegetables), Sport fields, parks

111

Annex (4.3b): Limit Values for Effluent Reuse (PS 742/2003)

Parameter

(mg/l)

Discharge to

sea

(500 m)

Recharge Dry

fodder

Fresh

fodder

Parks and

gardens

Industrial

and cereal

crops

Trees and

forests

Fruit

trees

COD 200 150 200 150 200 200 150

DO >1 >0.5

TDS - 1500 1200 1500

pH 6-9

FOG 10 0 5

Phenol 1 0.002

MBAS 25 5 15

NO3-N 25 15 50

NH4-N 5 10 - 50 -

Organic N 10 10 50

Cl - 600 500 350 500 400

SO4 1000 500

Na - 230 200

Mg - 150 60

Ca - 400 400

SAR - 9 10 9

PO4-P 5 15 30

Al 5 1 5

Ar 0.05 0.1

Cu 0.2

Fe 2 5

Mn 0.2

Ni 0.2

Pb 0.1

Se 0.02

Cd 0.01

Zn 5 2

CN 0.1 0.05

Cr 0.5 0.05 0.1

Hg 0.001

Co 1 0.05

B 2 1 0.7

Pathogens Free

Protozoa(1)

(cyst/l) Free - Free -

Nematodes

(eggs/l) <1

112

Annex (5): Location of Sheikh-ejleen pilot project area

Figure(2.1): Location of Sheikh-ejleen pilot project area, source (Austrian

Development Cooperation and Palestinian National Authority, 2013)

Annex (6): Post wastewater treatment system layout, source

Figure(2.2): Post wastewater treatment system layout, source (Austrian Development

Cooperation and Palestinian National Authority, 2013)

Reed beds

WWTP

Gaza

Slow sand filtration

Effluent conveyor to

farmers

Storage

bed

113

Annex (7): Interview questionnaire with consent form

Annex 7a: Interview questionnaire with consent form (English version)

Consent Form for participation in scientific thesis My Brother Farmer:

I'm the researcher: Haneen Nabil Al-Sbaihi, I'm studying at Al-Quds University (Abu Dees) in Public Health

collage –I'm preparing Research about Parasitic Infection between Farmer dealing with Treated Wastewater in

Azaitoun Area – Gaza City (Comparative Study).

As a prerequisite for my Graduation and obtaining on the Master degree in Public Health – Epidemiology.

The research mainly aims to identify the parasitic infection between farmer dealing with Treated Wastewater by

comparison it with the infection between farmer dealing with groundwater.

To perform this research, farmers who use the treated wastewater in agriculture in Azaitoun area beside Gaza car

shop (west of Salah El-Deen street) and farmers who use the ground water in Johur El-Deek area (east of Salah

El-Deen Street) are chosen as sample for this research.

This research require from each farmer to fill one questionnaire (20 min) , and provide stool, hand

washing water, soil, and irrigation water (GW/TWW) samples.

Your participation is voluntary, In case of you approved to participate, we prefer to commit in answering the

questionnaire and providing the required samples.

You can refused to answer any question in the questionnaire, and I would like to confirm that all information you

mentioned will be secret, and will be used for scientific research purposes only without mention your names,

since the results will not spread in special form, will spread in general, and there is no anything will related to

you.

Research possibly will put the necessary recommendation that will contribute in providing sufficient safely

degree for farmers.

This research obtained on Helsinki approval, the approval copy attached in the end of the questionnaire.

Your cooperation are highly appreciated

Researcher: Haneen Al-Sbaihi

Based on the previous I confess: The researcher Haneen Nabil Al-Sbaihi from Al-Quds University, informed me about the research and answered on my questions

and enquires completely.

And based on that, I accept to participate in the research , by filling the questionnaire and providing the required samples through the previous coordination, in

addition to I know I'm free and I have the right to withdrw in anytime, without clarify the reasons and without my withdrawal effect on my right to benefit from

the research results; even if this withdraw happened after this written approval, but it's better to commit in order to contribute in performing the research

successfully and obtaining on recommendation contribute in providing sufficient safely degree for me and other farmers.

Farmer Name: Signature: Date: / /

114

1. General Information about Farmer

Farmer's name: ………………………. Phone number:…………………… 1.1

…………………………………………. Farmer's address 1.2

∕ Male ∕ Female Gender 1.3

1111111111111111111111111111111 Age (Years) 1.4

∕Primary or less ∕ Preparatory - General secondary

∕Bachelors/Diploma ∕ High studies Academic qualification 1.5

11111111111111111111111111111 Family size 1.6

∕Yes ∕ No Is farming your main job 1.7

If No, What's your main job: ……………………………………………. 1.7.1

111111111111111111111111111111 Years of working in

agriculture

1.8

∕Yes ∕ No Do any one assist/ share

you working in agriculture

1.9

∕Father ∕ Mother ∕Wife ∕ Sons ∕ Brothers/Sisters

∕Others(Identify)…….

If yes, Who are those

people

1.9.1

∕ Excellent ∕ Very good ∕ Good ∕Bad How do you describe your

financial and economic status

1.10

2. Farmer's home: ∕ Concrete ∕ Asbestos ∕ Other (Identify) ……………… What's the type of your home 2.1

meter 11111111111111111111 What's the distance between

your home and the closest

home of your neighbors

2.2

∕ Other (Identify) wood ∕ Soil ∕ Court ∕ Concrete ∕ What's the type of your home

land 2.3

Other (Identify) ∕ Soil∕ Grass∕ Concrete∕ What's the type of the land

around your home 2.4

Date: ……………………….

Time:……………………….

Questionnaire No..……………….

111

3. Agriculture: ……………………….………….

What's the address of the farm that

you work or have

3.1

∕Home exists inside farm ∕Farm beside/close from farmer home ∕ Farm is far away from farmer

home

1111111111111111111111 hour/day How much time do you spent in the

farm

3.2

……………………….. dounm What are the area of your agri. land 3.3

∕Trees (specify types)………….

∕Fodders (specify types)………….

∕Vegetables (specify types)………….

∕Other (specify types)………….

Mention the cultivated plants in you

farm

∕Yes ∕No Do you fertilize your farm 3.4

∕ Animal manure ∕ birds manure

∕ chemical fertilizers ∕ Sludge

∕more than one type (specify) …..

If the answer is Yes,

what's the type of

fertilizers that you use

3.4.1

…………………………….. What's the source of the used

fertilizers

3.5

The following questions are for farmers who use TWW in Agriculture

…………………………………… dounm How many donums do you irrigate

by TWW

3.6

1111111111111111111111111111111111111111 year How long have you been using

TWW in Agriculture

3.7

∕Fruits trees (specify types)………….

∕Olive

∕Fodders (specify types)………….

∕Other (specify types)………….

Mention the cultivated plants in you

farm

∕

Sometimes

∕ No ∕Yes Do you eat from Crops irrigated be

TWW

3.9

∕

Sometimes ,

at need

∕ No ∕ Yes Do you fertilize your farm when you

use TWW in irrigation

3.10

∕ Animal manure ∕ Birds manure If the answer is Yes,

what's the type of fertilizer

that you use

3.10.1

∕ More than one type

(Identify) …………………….

∕ Chemical

Fertilizers

…………………………….. What's the source of the

used fertilizers

3.10.2

120

4. Water

∕Private water plants

(Desalination water plant)

∕Municipality water What are the sources of drinking water

you supply your home with

4.1

∕Rain water ∕Agricultural well ∕Private well

∕Private well ∕Municipality water What are the sources of non- drinking

water that supply your home

4.2

∕Rain water ∕Agricultural well

∕ Yes ∕ No ∕Sometimes Do you do anything before drinking

water in order to improve its quality

4.3

∕Chlorination ∕Boiling ∕Chlorination + Boiling ∕

filtration ∕ other

If your answer is Yes,

mention the methods you

use

4.3.1

111111111111111111111111111111111 (Liter/Family) What's the amount of daily consumed

water for purposes other than drinking

water

4.4

5. Sanitation

∕Pumped for septic tanks ∕Pumped for farm Where do you get rid of sanitation in

your home

5.1

∕Other (identify) ……… ∕Pumped to WW

network

∕No ∕Yes Do you have toilet in the farm 5.2

If your answer is Yes:

∕ No

∕ Yes Do other farmers share the

toilet with you

5.2.1

Number: …………….

∕Pumped for septic tanks ∕Pumped for farm where do you get rid of

sanitation in the farm toilet

5.2.2

∕Other (identify) ……… ∕Pumped to WW network

If your answer is No:

∕Between plants ∕On the edge of the farm where do you go to

Urinating while you are at the farm

5.2.3 ∕Other (identify) ….. In home toilet ∕

121

6. Birds and Animals Breeding ∕ Yes ∕No Do you breed birds and/or animals 6.1

If the answer is yes, ∕ Inside the home

∕In the farm

∕ outside home garden

∕Other (identify):……….

Where do you breed brides and

animals

6.1.1

∕ Yes ∕ No

If your previous answer are

inside home or in the farm, Do

the birds and animals exist in

closed place

6.1.2

∕ Yes ∕ No Do the birds and animals that

you breed eat the agricultural

remaining

6.1.3

∕Other

(Identify)

……..

∕Cattle

∕ Birds ∕ Dogs ∕ Cats What are the birds and animals

that you breed

6.1.4

7. Farmer health behavior ………………………………(Peace/week) What's the quantity of soap consumption in

your house per week 7.1

∕outside home ∕inside the home

but is not in assigned room

where often do you cook

Where is most of the cooking done

7.2

∕in home kitchen

∕ Never ∕ rarely ∕ Almost ∕Always Do you wear shoes when going out

7.3

∕ No ∕ Yes Is there a faucet in or around there the

house 7.4

∕ Never ∕ rarely ∕ Almost ∕Always How often do use this faucet 7.5

∕ Never ∕ rarely ∕ Almost ∕Always Is there a soap in your farm? 7.6

122

The below questions (7.6-7.16) enquired about the irrigation period with using groundwater and

then about the irrigation period with using treated wastewater

∕ Never ∕ rarely ∕ Almost ∕Always When you are in the farm , How often do

you wash fruit and vegetables before eating

them?

7.7

∕ Never ∕ rarely ∕ Almost ∕Always

∕ Never ∕ rarely ∕ Almost ∕Always How often do you wash your hands after

you operate the water/ TWW pump to

irrigate the farm

7.8

∕ Never ∕ rarely ∕ Almost ∕Always

∕ Never ∕ rarely ∕ Almost ∕Always How often do you wash your hands after

you maintain any faults in irrigation

network

7.9

∕ Never ∕ rarely ∕ Almost ∕Always

∕ Never ∕ rarely ∕ Almost ∕Always How often do you wash your hands when

they had touch soil 7.10

∕ Never ∕ rarely ∕ Almost ∕Always

∕ Never ∕ rarely ∕ Almost ∕Always How often do you had touch with the

irrigation water 7.11

∕ Never ∕ rarely ∕ Almost ∕Always

∕ Never ∕ rarely ∕ Almost ∕Always When you are in the farm , do you use

water for washing hands used multiple

times?

7.12

∕ Never ∕ rarely ∕ Almost ∕Always

∕ Never ∕ rarely ∕ Almost ∕Always Do you use special footwear when you

work in the field 7.13

∕ Never ∕ rarely ∕ Almost ∕Always ∕ Never ∕ rarely ∕ Almost ∕Always Do you use special gloves when you work

in the field 7.14

∕ Never ∕ rarely ∕ Almost ∕Always ∕ Never ∕ rarely ∕ Almost ∕Always Do you use special clothes when you work

in the field 7.15

∕ Never ∕ rarely ∕ Almost ∕Always

∕get rid

them

∕wash them

very well

∕clean them

by my clothes

then I eat them

∕eat

them

directly

At harvest , how do you deal with the fruits

that fall to the soil if you want to eat them 7.16

∕get rid

them

∕wash them

very well

∕clean them

by my clothes

then I eat it

∕

collect

them

123

∕get rid

them

∕wash them

very well

∕clean them

by my clothes

then I eat them

∕eat

them

directly

At harvest for selling purposes , how do

you deal with the fruits that fall to the soil 7.17

∕get rid

them

∕wash them

very well

∕clean them

by my clothes

then I eat it

∕

collect

them

The following question are for farmers who use TWW in agriculture

∕ No ∕ Yes is groundwater used for irrigation two weeks before harvest

7.18

8. Health ∕ No ∕ Yes Have you ever been diagnosed with intestinal

parasites?

8.1

∕ Other,

specify

………

….

∕ Within the 3 last

month

∕ Within the

2 last month

∕ Within the last

month If yes, when was the diagnosis made? 8.1.1

∕ No ∕ Yes Do you previously had Anti-parasitic

drugs

8.1.2

Mention the type of parasites that

you had ?

8.1.3

Some of the questions are for treated wastewater users only:

∕ Bad ∕Accepted ∕ Good ∕Excellent In General, How do you evaluate your Health

status now

8.2

∕I can't

evaluate that

∕Bad than

previous

∕ Not differ about

previous How do you evaluate your health status before

using TWW in agriculture

8.3

∕I can't

evaluate that

∕Bad than

previous

∕ Not differ about

previous How do you evaluate your children health status 8.4

∕I can't evaluate

that

∕Bad than

previous

∕ Not differ

about

previous

How do you evaluate your children health status

after using TWW in agriculture

8.5

∕ No ∕ Yes Do you think using TWW in agriculture

increased your diseases infection

8.6

…………………………………. If your answer is yes, mention these diseases 8.7

124

∕ No ∕ Sometimes ∕ Yes Did you have abnormal diarrhea 8.8

∕ No ∕ Sometimes ∕ Yes Did you have abnormal constipation 8.9

∕ No ∕ Sometimes ∕ Yes Did you have abnormal abdominal pain 8.10

∕ No ∕ Sometimes ∕ Yes Did you have abnormal stool with blood 8.11

∕ No ∕ Sometimes ∕ Yes Did you have abnormal vomiting 8.12

∕ No ∕ Sometimes ∕ Yes Did you have abnormal fever 8.13

∕ No ∕ Sometimes ∕ Yes Did you have abnormal weakness 8.14

∕ No ∕ Sometimes ∕ Yes Did you have abnormal headache 8.15

∕ No ∕ Sometimes ∕ Yes Did you have abnormal loss of appetite 8.16

125

Annex 7.b: Interview questionnaire with consent form (Arabic version)

إقرار موافقة بالمشاركة في بحث عممي "أطروحة عمميو"

:قوم بإعداد بحث بعنوانالعامة, أ( , كمية الصحة أبو ديس )جامعة القدس في رس أد : حنين نبيل الصبيحيالباحثةأنا , أخي المزارعدراسة مقارنة", " -مدينة غزة –ممياه العادمة المعالجة في منطقة الزيتون ل مستخدمينالالطفيمية بين المزارعين ىالعدو

عمم األوبئة –في الصحة العامة تخرج والحصول عمى درجة الماجستيرلمباعتباره متطمب

عن طريق مقارنتيا بالعدوى الطفيمية بين العدوى الطفيمية بين المزارعين مستخدمين المياه العادمة المعالجة البحث إلى تحديد ىذايدف ي الجوفية مياهلممستخدمين الالمزارعين

غرب ) بالقرب من سوق سيارات غزة –إلجراء ىذا البحث تم اختيار المزارعين المستخدمين لممياه العادمة المعالجة في منطقة الزيتون الجوفية في منطقة جحر الديك ) شرق شارع صالح الدين( مياهشارع صالح الدين( والمزارعين المستخدمين لم

دقيقة( و تقديم عينات براز, عينات من مياه غسيل يديو "أثناء عممو في المزرعة" , 20البحث يتطمب من كل مزارع تعبئة استبيان ) ادمة معالجة/ مياه جوفية(.عينات تربة, و عينات مياه ري) مياه ع

, و في حال موافقتك عمى المشاركة يفضل االلتزام بإجابة االستبيان وتقديم العينات المطموبة. مشاركتك تطوعية و أرغب أن أؤكد لك أن المعمومات التي تذكرىا ستكون مصدر ثقة وسرية وستستخدم في االستبيان يمنك رفض اإلجابة عن أي سؤال

لن تنشر بشكل خاص و انما سوف تنشر بشكل جماعي ولن ينسب أي شيء جفالنتائ ذكر األسماء حث العممي وبدونفقط لغرض الب اليك,

عمما بأن نتائج البحث سوف تساىم في وضع التوصيات الالزمة من أجل الوصول الى درجة كافية من السالمة لممزارعين. أرفقت الموافقة في نياية االستبيان. , وقدىمسنكيوقد تم حصول البحث عمى موافقة لجنة

.وشكرا لك عمى حسن تعاونك الصبيحي نبيل الباحثة / حنين

بناء عمى ما سبق, أقش أب اىقغ أدب: 11111111111111111111111111111111111111111111111111111

ذش اىز رق ث جشبر فائذ اىذزيخ, قذ أجبثذ ثأ اىجبدضخ د جو اىظجذ جبؼخ اىقذط , قذ أطيؼز ػي طجؼخ اىج ػ مو اعزفغبسار أعئيز ثضح ػي أمو ج1

ثبء ػي فئ ثبخزبس أافق ػي اىشبسمخ ف اىجذش رىل ثزؼجئخ اعزجبخ خ اىجبدضخ اىؼبد اىطيثخ خاله اىزغق اىشبسمخ االغذبة زا اىجذش ز شئذ ى ثؼذ اىافقخ اىزذششخ ثذ اثذاء االعجبة اىغجق, مب أػي ربب ثأ دش ف

د ا ؤصش ػي دق ف االعزفبدح زبئج اىجذش, اال ا فضو االىزضا اىزب أجو اىغبخ ف اجبح رفز اىجذش 1ه اى دسجخ مبفخ اىغالخ ى ىغش اىضاسػاىذظه ػي زبئج رغب ف ضغ اىزطبد االصخ ىيط

اسم المشارك : التاريخ: / / التوقيع:

126

: عن المزارع معمومات عامة .1

1.1 : ..........................رقم الجوال: ........................................ اسم المزارع

1.2 عنوان المزارع ...........................

1.3 الجنس أنثى ⧵ ذكر ⧵

1.4 )بالسنوات( العمر ...............................

1.5 المؤىالت العممية دراسات عميا ⧵ سدبموم /بكالوريو ⧵ ثانويو عامو –إعدادي ⧵ ابتدائي فأقل⧵

1.6 عدد أفراد األسرة .............................

1.7 الزراعة مينتك الرئيسية تعد ىل ال ⧵ نعم ⧵

1.7.1 : ........................................................ اذا كانت اإلجابة ال, ما ىي وظيفتك الرئيسية

1.8 عدد سنوات العمل في الزراعة ..............................

ىل يقدم لك المساعدة/يشارك العمل في ال ⧵ نعم ⧵ الزراعة أشخاص آخرين

1.9

الزوجة ⧵األ ⧵ األة ⧵ , حدد........أخش⧵ األخح ⧵ األبناء ⧵

1.9.1 , اذكر األشخاص الذين يشاركونك العمل اذا كانت اإلجابة نعم

1.10 كيف توصف الوضع المادي لعائمتك سيء ⧵ جيد ⧵ جيد جدا ⧵ممتاز ⧵

السكن / المنزل: .2

2.1 لمنزلنوع ا )حدد( ................. أخرى ⧵( )اسبستمنزل ⧵ )باطون( منزل ⧵

2.2 منزلك من منزلالمسافة التي يبعدىا اقرب ما ىي .................... متر 2.3 منزلكأرضية ما ىي طبيعة اسمنت⧵ بالط ⧵ تربة ⧵ خشب⧵ ى)حدد(.........أخر ⧵

2.4 المنزلنوعية االرض حول ما ىي اسفمت⧵ عشب⧵ تربة ⧵ )حدد(....................... أخرى ⧵

.………………………: التاريخ

.………………………الوقت:

127

:الزراعة .3

3.1 / تعمل فيياعنوان المزرعة التي تمتمكياما ىي المنطقة:.................

المزرعة بعيدة جدا عن ⧵ المنزلالمزرعة قريبو من ⧵يقع البيت بداخل المزرعة ⧵ المنزل

3.2 المزرعة الزمن الذى تقضيو في ...................... ساعو/يوم

3.3 مساحة المزرعة ...................... دونم

)حدد األنواع(:.......................أشجار ⧵

)حدد األنواع(:....................... أعالف ⧵

خضراوات )حدد األنواع(:..................... ⧵

أخرى )حدد( ................................ ⧵

3.4 بزراعتياالتي تقوم المزروعات اذكر

ىل تستخدم الروث كسماد لتسميد أرضك ال ⧵ نعم ⧵ الزراعية

3.5

حيوانات روث ⧵ روث طيور ⧵ سماد كيميائي ⧵حمأة ⧵ , )حدد(.....................أكثر من نوع ⧵

3.5.1 التي تستخدميا الروثنوع وى ما اذا كانت اإلجابة بنعم,

3.5.2 ما ىو مصدر الروث الذى تستخدمو ........................................

عةلممزارعين الذين يستخدمون المياه العادمة المعالجة في الزرا سلمة التاليةاأل

3.6 المساحة التي تروييا بالمياه العادمة المعالجة دونم ……………………………………

3.7 في الزراعة المعالجة المدة الزمنية الستخدامك المياه العادمة ........................................ سنو

)حدد األنواع(:................... أشجار فواكو ⧵

أشجار زيتون ⧵

)حدد األنواع(:....................... أعالف ⧵

................................أخرى )حدد( ⧵

المزروعات التي يتم رييا بالمياه العادمة اذكر المعالجة

3.8

3.9 بالمياه العادمة المعالجةىل تتناول المحاصيل المروية نعم ⧵ ال ⧵ أحيانا ⧵

أحيانا عند ⧵ الحاجو

المساحات الزراعية المروية بالمياه العادمة ىل تستخدم الروث كسماد لتسميد نعم ⧵ ال ⧵ المعالجة

3.10

3.10.1 التي تستخدميا الروثنوع وما ى اذا كانت اإلجابة بنعم, روث الطيور ⧵ روث الحيوانات ⧵

, حدد أكثر من نوع ⧵)......(

سماد ⧵ كيميائي

3.10.2 ما ىو مصدر الروث الذى تستخدمو ......................................

128

المياه .4

4.1 بالمياه الصالحة لمشرب المنزلمصادر تزويد البمدية ⧵ محطات تحمية المياه الخاصة ⧵

بئر خاص ⧵ بئر زراعي ⧵ مياه األمطار ⧵

4.2 بمياه أغراض غير الشرب المنزلمصادر تزويد البمدية ⧵ بئر خاص ⧵ بئر زراعي ⧵ مياه األمطار ⧵

4.3 قبل استخداميا ألغراض الشرب ىل تقوم بعمل أي شيء من اجل تحسين جودة المياه أحيانا ⧵ ال ⧵ نعم ⧵ فمترة ⧵ غمي ⧵ كمورة ⧵

, حدد .........أخرى ⧵ 4.3.1 إذا كانت اإلجابة بنعم , ما ىي الطرق المستخدمة

4.4 ألغراض غير الشرب يوميا كمية المياه المستيمكة ................................. )لتر/عائمة(

الصحيالصرف .5

5.1 لمنزلك أين يتم التخمص من مياه الصرف الصحي تضخ لممزرعة ⧵ حفر امتصاصيةتضخ الى ⧵تضخ الى شبكة الصرف ⧵ )حدد(............. أخرى ⧵

الصحي

5.2 ىل يوجد مرحاض في المزرعة نعم⧵ ال⧵

اذا كانت االجابة نعم:

ال⧵

مزارعين المرحاض ىل يشاركك في استخدام نعم⧵ اخرين

5.2.1

العدد: ..................

5.2.2 مرحاض المزرعةأين يتم التخمص من مياه تضخ لممزرعة ⧵ حفر امتصاصيةتضخ الى ⧵

تضخ الى شبكة الصرف ⧵ )حدد(.... أخرى ⧵ الصحي

اذا كانت االجابة ال

في وسط ⧵ المزروعات

5.2.3 اين تقضى احتياجاتك من التبول وغيره اثناء العمل في المزرعة في اطراف المزرعة ⧵

أخرى ⧵ )حدد(.........

المنزلفي مرحاض ⧵

129

تربية الحيوانات و الطيور .6

6.1 حيوانات وطيور بىتر ىل ال ⧵ نعم ⧵

اذا كانت اإلجابة نعم:⧵ اىضسػخ ىيجذ ف⧵ اىخبسجخ ىيجذف اىذذقخ ⧵ داخل البيت ⧵

أخش )دذد( 1111111111111111111

6.1.1 اين تربى الحيوانات والطيور

تإذا كانت االجابة السابقة المزرعة أو داخل البيت , فيل تتواجد الحيوانا أحيانا ⧵ ال ⧵ نعم ⧵ والطيور في مكان مغمق خاص فييا في المزرعة أو داخل المنزل

6.1.2

6.1.3 ىل بقايا وخمفات الزراعة تتناوليا الحيوانات والطيور ال ⧵ نعم ⧵

6.1.4 التي تربييا الحيوانات والطيور ما ىى القطط ⧵ الكالب ⧵ الطيور ⧵ الماشية ⧵ أخرى, حدد .... ⧵

السموك الصحي: .7

7.1 المنزلكمية استيالك الصابون في ما ىي )قطعة / اسبوع( ………………………………

مطبخفي ⧵ في خارج السكن ⧵ السكن

ليس فى ) في داخل السكن ⧵ (غرفة محددة

7.2 في منزلكاين تحدث معظم عمميات الطيى

7.3 عند التنقل في محيط منزلك تمبس حذاء عادةىل دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

7.4 لغسيل يديك/طعامك عند الحاجو مياه في المزرعة صنبورلديك ىل نعم ⧵ ال⧵

7.4.1 اذا كانت اإلجابة نعم, ما ىو مصدر ىذا الصنبور .................................

7.4.2 المياهمدى استعمالك لصنبور دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

7.5 في المزرعة لديك صابونىل أبدا ⧵نادرا ⧵غالبا ⧵دائما ⧵

تتضمن السؤال عن فترات الري باستخدام المياه الجوفية / مياه اآلبار وفترات الرى باستخدام المياه 7.16 - 7.6من التاليةاألسلمة العادمة المعالجة

7.6 اأثناء تواجدك في المزرعة تغسل الفواكو والخضروات قبل تناولي دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

تغسل يديك بعد تشغيل مضخة ضخ المياه العادمة المعالجة/ المياه دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ الجوفية لري المزروعات

7.7

دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

130

7.8 تغسل يديك بعد صيانو أي عطل في شبكة ري المزروعات دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

7.9 تغسل يديك بعد مالمستيم لمتربة دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

7.10 يحدث تالمس مع مياه الري دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

7.11 اه الريتغسل يديك بعد مالمستيم لممي دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

7.12 اثناء تواجد في المزرعة تغسل يديك باستخدام ماء سبق استخدامو عدة مرات دائما ⧵ غالبا ⧵ أبدا ⧵ نادرا ⧵ 7.13 / حذاء مغمقأثناء عممك في المزرعة تستخدم حذاء خاص دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ 7.14 العمل في الحقلترتدى قفازات عند دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ 7.15 ترتدى مالبس خاصة عند العمل في الحقل دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵ دائما ⧵ غالبا ⧵ نادرا ⧵ أبدا ⧵

اتخمص ⧵ منيا

امسحيا بمالبسي ⧵ اغسميا جيدا ⧵ أتناولياثم

اتناوليا ⧵ مباشرة

كيف تتعامل مع الثمار التي تسقط عند الحصاد, عمى التربة اذا كنت ترغب بتناوليا

7.16

اتخمص ⧵ منيا

امسحيا بمالبسي ⧵ اغسميا جيدا ⧵ أتناولياثم

اجمعيا ⧵

اتخمص ⧵ منيا

امسحيا بمالبسي ⧵ اغسميا جيدا ⧵ أتناولياثم

اتناوليا ⧵ مباشرة

الثمار عند الحصاد من أجل البيع, كيف تتعامل مع التي تسقط عمى التربة

7.17

اتخمص ⧵ منيا

امسحيا بمالبسي ⧵ اغسميا جيدا ⧵ أتناولياثم

اجمعيا ⧵

السؤال التالي لممزارعين مستخدمي المياه العادمة المعالجة في الزراعة ال ⧵

7.18 ىل يتم الري بالمياه الجوفية قبل الحصاد بأسبوعين نعم ⧵

الصحة .8 8.1 لمطفيميات المعوية ا ن اجريت فحصأىل سبق و نعم ⧵ ال ⧵

اذا كانت االجابة نعم, خالل الثالث ⧵ أخرى, حدد .......⧵

أشير الماضيةخالل الشيرين ⧵

الماضيةخالل الشير ⧵

الماضي 8.1.1 متى قمت بإجراء ىذا الفحص

131

8.1.2 مضادة لمطفيميات بأدويةتعالجت ىل نعم ⧵ أحيانا ⧵ ال ⧵

الكشف عنيا خالل الفحص الذى اجريتو تم التي الطفيمياتاذكر نوع 11111111111111111111111111111

8.1.3

المياه العادمة المعالجة في الزارعة فقط: نبعض االسلمة التالية لمستخدمي 8.2 بشكل عام , كيف تقيم وضعك الصحي االن ممتاز ⧵ جيد ⧵ مقبول ⧵ سيء ⧵

أسوأ من ⧵ ال أستطيع التحديد ⧵ السابق

لم يختمف عن ⧵ السابق

8.3 استخدام المياه العادمة المعالجة قبلكيف تقيم وضعك الصحي

8.4 ألطفالك ضع الصحي الو كيف تقيم ممتاز ⧵ جيد ⧵ مقبول ⧵ سيء ⧵

ال أستطيع ⧵ التحديد

أسوأ من ⧵ السابق

لم يختمف ⧵ عن السابق

8.5 استخدام المياه العادمة المعالجةألطفالك بعد ضع الصحي الو كيف تقيم

8.6 باألمراض اإلصابةساىم في زيادة يىل تعتقد ان استخدام المياه العادمة المعالجة في الزراعة نعم ⧵ ال ⧵

8.7 ىي ىذه االمراضما ف اذا كانت االجابة نعم, .…………………………………

8.8 اسيال ىل يحدث معك نعم ⧵ أحيانا ⧵ ال ⧵ 8.9 امساك معك حدثي ىل نعم ⧵ أحيانا ⧵ ال ⧵ 8.10 الم في البطن معكحدث ي ىل نعم ⧵ أحيانا ⧵ ال ⧵ 8.11 نزول دم مع البراز معك حدثي ىل نعم ⧵ أحيانا ⧵ ال ⧵ 8.12 استفراغ معكحدث ي ىل نعم ⧵ أحيانا ⧵ ال ⧵ 8.13 حمى معكحدث ي ىل نعم ⧵ أحيانا ⧵ ال ⧵ 8.14 ىزال/ضعف معكحدث ي ىل نعم ⧵ أحيانا ⧵ ال ⧵ 8.15 صداع معكحدث ي ىل نعم ⧵ أحيانا ⧵ ال ⧵

8.16 فقدان شييو معكحدث ي ىل نعم ⧵ أحيانا ⧵ ال ⧵

132

Annex (8): Expert Names who validated the interview questionnaire

# Name Position

1. Dr. Nahed Al Laham Associate Professor - Al Azhar University Gaza

2. Dr. Bassam El-Zain Associate Professor - Al Quds University Gaza

3. Dr. Jehad El-Hissi PHD - Al Azhar University Gaza

4. Dr. Yousef Abu Safia PHD - Al Quds University Gaza

5. Dr. Abood El-Qeshawi Associate Professor – Islamic University of Gaza

6. Dr. Abdelfatah Abdrabou Associate Professor - Islamic University of Gaza

7. Dr. Thaer Abu Sbak PHD - Al Azhar University Gaza

8. Dr. Khitam Abu Hamad PHD - Al Quds University Gaza

9. Dr. Basam Abu Hamad Associate Professor - Al Quds University Gaza

10. Dr. Yehia Abd PHD - Al Quds University Gaza

11. Dr. Amal Sarsor Environmental Health Consultant - Earth and

Human Center for Researches and studies

12. Dr. Mohammed Abu Hashish PHD - Al Quds University Gaza

13. Dr. Yosef El-Jesh Associate Professor - Islamic University of Gaza

14. Dr. Adnan Ayesh PHD - Al Azhar University Gaza

15. Dr. Reyad Jaber Assistant Professor - Islamic University of Gaza

16. Prof. Abdelraouf A. Elmanama Professor - Islamic University of Gaza

133

Annex (9): Helsinki Committee Approval Letter

134

Annex (10) : Stool analysis report for medical treatment

135

Annex (11) : Medicine prescriptions

136

Annex (12): Comparison between parasitic infection and contamination by figures

Parasitic infection/load (No. of positive and negative) in stool, soil, irrigation water, and

hand washing water samples at the two rounds

Comparison of parasitic infection/load in stool, soil, irrigation water, and hand washing

water samples between the two groups at the two rounds, (only for positive samples)

0 10 20 30 40 50 60

Stool samples (+ve)

Stool samples (-ve)

Soil samples (+ve)

Soil samples (-ve)

Irrigation water samples (+ve)

Irrigation water samples (-ve)

Hand washing water samples (+ve)

Hand washing water samples (-ve)

2nd

1st

0

5

10

15

20

25

MWUs GWUs

Stool samples (1st)

Stool samples (2nd)

Soil samples (1st)

Soil samples (2nd)

Hand washing watersamples (1st)

Hand washing watersamples (2nd)

Irrigation water samples(1st)

137

Comparison of parasitic infection/load in stool, soil, irrigation water, and hand washing

water samples between the two groups at the two rounds, (positive and negative samples)

0

5

10

15

20

25

30

35

40

MWUs GWUs

Stool samples (1st) (+ve)

Stool samples (1st) (-ve)

Stool samples (2nd) (+ve)

Stool samples (2nd) (-ve)

Soil samples (1st) (+ve)

Soil samples (1st) (-ve)

Soil samples (2nd) (+ve)

Soil samples (2nd) (-ve)

Irrigation water samples (1st) (+ve)

Irrigation water samples (1st) (-ve)

Irrigation water samples (2nd) (+ve)

Irrigation water samples (2nd) (-ve)

Hand washing water samples (1st)(+ve)Hand washing water samples (1st) (-ve)Hand washing water samples (2nd)(+ve)Hand washing water samples (2nd)(-ve)

138

Annex (13): Parasities detected in the collected samples

Parasites were found in soil samples

Size (X40): L*W (18.25*12) µm

Size (X40): L*W (8*8) µm

Size (X40): L*W (6.25*4) µm

Size (X40): L*W (16.25*11.75)

µm

Size (X40): L*W (13.25*9.25)

µm

Size (X40): L*W (15*8.75) µm

Size (X40): L*W (11.25*7) µm

139

Parasites were found in soil samples

140

Parasites were found in soil samples

141

Parasites were found in soil samples

142

Parasites were found in soil samples

143

Parasites were found in soil samples

144

145

146

Parasites were found in wastewater samples

147

Parasites were found in wastewater samples

All photos for the same female adult

148

Parasites were found in Hand washing water samples

149

Parasites were found in hand washing water samples

150

Parasites were found in stool samples

Entamoeba coil cyst

Entamoeba

histolytica/dispar cyst

Giardia lamblia

cyst

Ascaris lumbricoides egg

Cryptosporidium sp.

occyst

Microsporidia sp. oocyst

151

Annex (14): Relation between Age variable and other variables

Annex 14.1: Relation between Age variable and agricultural factors

#

Variable

Age Pears

on

Chi-

squar

e

P

value ≤ 18 year 19-46 year ≥ 46 year

Fre

q.

% Freq. % Freq. %

1. Is farming

your main job

Yes 2 6.9 15 51.7 12 41.4

26.8

0.001* No 19 73.1 6 23.1 1 3.8

Total 21 38.2 21 38.2 13 23.6

2. Time of

working in

agriculture per

day

18 52.9 11 32.4 5 14.7

8.87

0.012* 3 14.3 10 47.6 8 38.1

Total 21 38.2 21 38.2 13 23.6

3. Years of

working in

agriculture

2 – 5 years 19 82.6 4 17.4 0 0

34.2

0.001* ≥ 6 years 2 6.3 17 53.1 13 40.6

Total 21 38.2 21 38.2 13 23.6

4. Years of using

TWW in

Agriculture

2 – 5 years 13 56.5 7 30.4 3 13

1.55

0.212 ≥ 6 years 4 30.8 6 46.2 3 23.1

Total 17 47.2 13 36.1 6 16.7

5. Soil

contamination

(1st)

positive 13 43.3 10 33.3 7 23.3

0.868 0.648

Negative 8 32 11 44 6 24

Total 21 38.2 21 38.2 13 23.6

6. Soil

contamination

(2nd

)

positive 10 31.3 14 43.8 8 25

1.004 0.605

Negative 9 45 7 35 4 20

Total 19 36.5 21 40.4 12 23.1

Annex 14.2: Relation between Age variable and farmers' group

Variable

Parasitic Infection Pearson

Chi-

square

P value

MWUs GWUs

Freq. % Freq. %

Age

≤18 years 17 81 4 19

4.48

0.106

19-45 years 13 61.9 8 38.1

≥ 46 years 6 46.2 7 53.8

Total 36 65.5 19 34.5

152

Abstract (Arabic language)

ذخ غضح –اىؼا : اىؼذ اىطفيخ ث اىضاسػ اىغزخذ ىيب اىؼبدخ اىؼبىجخ ف طقخ اىضز

اػذاد : د جو اىظجذ أ1د1 ػذب اىذ اششاف: د1 خبىذ قذب

اىشئغ زضو اىذفشرجظ اىش ثبعزخذا اىب اىؼبدخ اىؼبىجخ ثفائذ زؼذدح ىن قذ ؤد إى خبطش طذخ1 يخض:ز اىذساعخ ف االعزقظبء ػ اىؼذ اىطفيخ ث اىضاسػ اىز غزخذ اىب اىؼبدخ اىؼبىجخ ف طقخ اىضز، ذخ

اىز اىضاسػ، اىب اىؼبدخ اىؼبىجخػز اىضاسػ: اىضاسػ اىز غزخذ شيذ ز اىذساعخ ج 1غضح

قذ رطيت مو ضاسع رؼجئخ اعزجب, رقذ ػبد ثشاص, رشثخ, ب س, ب ىب اىجفخ ف س اىضسػبد1 غزخذ ا

غغو اىذ ػي شديز1 ,ذاسعخاألى إى ضب أ ن اىضاسػ غش ظبث ثبىطفيبد قجو اىجذء ثبىشديخ اىضبخ ىيرذف اىؼبد ف اىشديخ

1 مبذ اىشديخ اىضبخ رذف ىقبسخ ثبىطفيبد اىش, ب غغو اىذ ب اىزشثخ, ذ ريسإشبء ؼيبد أعبعخ ده

ىذح صالصخ أشش غ شاػبح ثؼذ اعزخذ ىيب اىؼبدخ اىؼبىجخ ؼبدخ اىؼبىجخ اىب اىازشبس اىؼذ اىطفيخ ػذ غزخذ

غجخ اىطفيبد ف اىزشثخ ف ب اىش ػذ مو ضاسع فقب اىؼيبد األعبعخ1جذد 1%47111 صاد ف اىشديخ اىضبخ ىظو % 1.13ث اىشبسم اىطفيخ ف اىشديخ االى اىؼذؼذه ازشبس مب

اىشديخ اىضبخ فػالقخ طشدخ راد دالىخ ادظبئخ ؼخ ث اعزخذا اىب اىؼبدخ اىؼبىجخ اىؼذ اىطفيخ (OR=1.37, CI 0.448-4.21) 1 قذ ر اىزؼشف ػي عزخ أاع اىطفيبد ىذ اىضاسػ ف ز اىذساعخ

غج/ خ ىي ىخ اىذبى زذ زغشح/ اىزذىخ اىقىخاى اىجبسدخ , خاىفطشبد اىجغ, خفخ األثاؽ أجب داخيخ ؼخ،/اىزذىخ اىجيخ، ، االعطاخ اىجشاصخ / اىذدح اىخطخاىي فش اىخشاط 1اىظ

, جذد ػالقخ %5.45ىظو ف اىشديخ اىضبخ % صاد5.45 ف اىشديخ االى يبد ف اىزشثخازشبس اىزيس ثبىطفمب ف اىشدز ػي اىزاى ORػنغخ ىغذ راد دالىخ ادظبئخ ؼخ ث ريس اىزشثخ ثبىطفيبد ظذس اىش دش مبذ قخ

(OR1st =0.813, CI 0.265-2.495) and (OR2nd =0.897, CI 0.28-2.876) ث اإلبس، اىشبسم اىز ىذ أد ؤو ػي, اىشبسم اىز مبذ أػي غجخ ػذ طفيخ أ رطيذ اىذساعخ اى

عاد, اىز ؼي ف اىضاسػخ 1.≥عخ، اىشبسم اىز مبا ؼي ف اىضساػخ ىذح 1.≥ قؼ ف اىفئخ اىؼشخ عبػبد ب1 5≥ ىذح، دش مبذ ىؼقبقش اىضبدح ىيطفيبد عبثقبث دج األعشح اىشبسم اىز اعزخذا ا جد ػالقخ راد دالىخ إدظبئخ رج

اىؼذ اىطفيخ اقو ىذ اىشبسم اىز ىذ دج األعشح أقو اىشبسم اىز مبا ف اىغبثق زبى اىؼقبقش اىضبدح ىيطفيبد1

, اىز ال زين ىز ؼب عء اىضغ اىبىاىذساعخ أضب اسرفبع غجخ اىؼذ اىطفيخ ث اىشبسم ا قذ أظشدش اىز ىب اىؼبدخ اىؼبىجخ ثؼذح ػ بصى، اىغزخذ اىجذد ضاسع، ؼي ف بطق سيخ داخو بصى

اىز غزخذ األعذح غ ب ثب اىظشف اىظذ, اىز ال ؼي ثشنو أعبع ف اىضساػخ، أمضشدبد صساػخ

ىجر شدبع اىظذشدبع ف ضسػز، اىز زخيظا ب اىظشف ىظ ىذاىظشف اىؼبىجخ، اىز

اىذابد أ اىطس ف أبم غش غيقخ شثاىز اىضسػخ ثضخب اى اىضسػخ إى اىذفش االزظبطخ ػي اىزاى، 1 اىز ىذ عيك ظبفخ شخظخ أقو ثبإلطبثخ ثبىطفيبد اىؼخ, رشخظداخو أ ثجبت ضاسػ، اىز عجق

عيك مب و ػب ثشنمب اعزالك اىب غش اىظبىذخ ىيششة ىنو شخض ف اى أقو ػذ اىشبسم اىظبث ثبىطفيخ

خاله ػيخ اىذظبد اىضهألشخبص اىز غزخذ ب اىظشف اىظذ اىؼبىجخ ف ا ىذأفضو اىظبفخ اىشخظخخاله فزشاد اعزخذا اىب ىيغزبد األفضو ضذ عيك اىظبفخ اىشخظخ ؼذهجذ ا 1اىضسػخأعأ خاله اىؼو ف

اىضساػخ1 فاىؼبدخ اعزخذا ب اىظشف اىطفيخ ثث اىؼذ ؼخ دالىخ إدظبئخ ىغذ راد طشدخرجذ ػالقخ إى أ اىذساعخ ذرطي

قذ ؼض اىؼبدخاقزشذ فقظ ثغزخذ اىب اىطفيخ صبدح راد دالىخ ادظبئخاىؼبىجخ ف اىش1 ىدع أ صبدح اىؼذ رشة صساػخ أقو فسغ صبدح عيك اىظبفخ اىشخظخ ىذ خاله اعزخذا اىب اىؼبدخ, ػي صبدح فشص اىؼذ ث

اىنبئبد اىذخ اىذققخ ف اىزشثخ ثضبدح اىاد اىؼضخ إى صبدح شبط ريس ثبىطفيبد, اعزخذا ىظب اىش ثبىزقظ ع ض 1. ≥% اىشبسم اىز قؼ ض اىفئخ اىؼشخ 11جد اى رأصش اعزخذا ب اىظشف اىؼبىجخ،

1اىضاسػ اىغزخذ ىيب اىؼبدخ اىؼبىجخ

1ىظبفخ اىشخظخ، اىؼذ اىطفيخب اىظشف اىظذ، اىب اىجفخ، ب اىظشف اىظذ اىؼبىجخ، عيك ا ميبد بخ: